nurse practitioner professional competency framework

2

“Werde, der du bist” - Friedrich Nietzsche

Colophon

Nurse Practitioner professional competency framework

Utrecht, January 2019

Jaap Kappert

Irma de Hoop

Translated by Ko Hagoort.

This document is downloadable from www.venvn.nl.

For any questions or comments on this document, please contact [email protected].

©V&VN 2019

Nurse Practitioner professional competency framework

http://www.venvn.nl/

mailto:[email protected]

3

Content

The Nurse Practitioner: ready for the future ............................................................ 5

1. The Nurse Practitioner: generalist and specialist .................................................. 8

1.1 Introduction ............................................................................................................... 8

1.2 The core of the discipline .......................................................................................... 8

1.3 The Nurse Practitioner: independent practitioner ................................................... 9

1.4 The coordinating practitioner ................................................................................... 9

1.5 The Nurse Practitioner: T-shaped professional ...................................................... 10

1.6 Generic competencies ............................................................................................. 12

2. The Nurse Practitioner: the shared competency area ......................................... 13

2.1 Introduction ............................................................................................................. 13

2.2 The CanMEDS competences of the NP ................................................................... 13

2.2.1 Practitioner with nursing and medical expertise ................................................. 15

2.2.2 Communicator ...................................................................................................... 17

2.2.3 Collaboration partner ........................................................................................... 19

2.2.4 Quality of care organizer ...................................................................................... 20

2.2.5 Health advocate ................................................................................................... 22

2.2.6 Academic and researcher ..................................................................................... 23

2.2.7 Self-confident professional .................................................................................. 25

3. The Nurse Practitioner somatic health care ........................................................ 29

3.1 Introduction ............................................................................................................. 29

3.2 Competency area of the NP somatic health care ................................................... 29

3.3 Method of working .................................................................................................. 30

3.4 Focus areas, areas of expertise and spectrum of treatment .................................. 30

3.5 The NP somatic health care as coordinating practitioner ...................................... 34

3.6 The NP somatic health care as co-care provider .................................................... 35

3.7 Specific competences of the NP somatic health care ............................................. 35

3.7.1 Competences regarding the focus area, area of expertise and spectrum of treatment 35

3.7.2 Competences regarding the treatment process .................................................. 36

4

4. The Nurse Practitioner mental health care ......................................................... 39

4.1 Introduction ............................................................................................................. 39

4.2 Competency area of the NP mental health care ..................................................... 39

4.3 Method of working .................................................................................................. 40

4.4 Focus areas, areas of expertise and spectrum of treatment .................................. 41

4.5 The NP mental health care as coordinating practitioner ........................................ 46

4.6 The NP mental health care as co-care provider ...................................................... 46

4.7 Specific competences of the NP mental health care .............................................. 46

4.7.1 Competences regarding the focus area, area of expertise and spectrum of treatment 47

4.7.2 Competences regarding the treatment process .................................................. 48

Literature .............................................................................................................. 50

Annex 1 Realization of the professional competency framework ............................... 54

Annex 2 Developments in the demand for care, care provision and health ................ 57

Annex 3 Development of the profession ...................................................................... 60

Annex 4 Collaboration with other healthcare professionals ........................................ 63

Annex 5 Glossary ........................................................................................................... 65

Literature ...................................................................................................................... 71

Cover photo: Nikki Hendriks (Nurse Practitioner mental health care in training)

5

The Nurse Practitioner: ready for the future

The Nurse Practitioner

Since she1 took office ten years ago, the Nurse Practitioner has convincingly proven her

added value in healthcare in the Netherlands – and thus her right to exist. This is evident

from the evaluation reports 'VoorBIGhouden' (De Bruijn-Geraets et al., 2015) and

'VoorBIGhouden 2' (De Bruijn-Geraets et al., 2016). At the beginning of 2019, more than

3,600 Nurse Practitioners were active; not only in specialist medical care, but also in

primary care, integrated primary/secondary health care and care for the elderly, mental

health care, care for the intellectually disabled, and work-related care.

In her treatment, the Nurse Practitioner focuses on care that contributes to the health,

functioning, quality of life and dignity of life of the care recipient, wherever it is needed,

both at home and in institutions. The Nurse Practitioner follows the patient journey and,

if necessary, looks beyond the boundaries of her own workplace.

The Nurse Practitioner is a connecting professional with generalist and specialist skills or

competences who takes on challenges in care as a collaboration partner with the care

recipient, the care team, and with others within and outside the care organization. She is

aware of transitions in care, for example of the shift from specialist medical care to

primary care or of the progressively stronger link between mental and somatic health

care, which makes coordination between practitioners increasingly necessary. She is a T-

shaped professional who acts as an independent practitioner in the role of coordinating

practitioner or co-care provider.

This professional competency framework describes the expertise of the Nurse

Practitioner somatic health care (NP) and that of the NP mental health care. A number of

competences are shared between the two NP types. In addition, each NP practices one

of the two specialties and disposes of the corresponding specialist competences.

Ready for the future

In an ageing society like the Dutch one, which is struggling with shortages of qualified

personnel, the available expertise should be used as efficiently as possible. This can be

done, for example, by task substitution2. In addition, the location of care provision is

shifting from institutions to the care recipient’s own living environment (Taskforce Zorg

op de Juiste Plek, 2018); a paradigm shift from illness to functioning is taking place;

(Kaljouw & Van Vliet, 2015) and also views on health are changing (Huber et al., 2011).

Under these circumstances, the NP, who combines nursing and medical expertise and

1 In this profile, the Nurse Practitioner is referred to as a ‘she’, to prevent the recurrent use of he/she, him/her. 2 Read more about this in annexes 2 and 3.

6

treatments, can make an important contribution. After all, NPs, as bridge-builders

between nursing and medicine, naturally think outside the boundaries of traditional care

domains.

The professional competency framework revised

This professional competency framework builds on the previously conceptualized

professional competency framework (Lambregts & Grotendorst, 2012). There are three

reasons for the revision. First, the Council for Nurse Practitioners (CSV) has decided to

reduce the previously distinguished five nursing specialties to two: somatic health care

and mental health care (Poortvliet & Uitewaal, 2017).

Secondly, on 1 September 2018 the statutory independent practice authority of the NP

became definitive; a milestone for the professional group. By acquiring this definitive

independent authority, the NP can continue to fulfil her role as an independent

practitioner in all care sectors.

Thirdly, certain social developments influence the demand for and supply of care, such

as the increase in the number of care recipients (with multimorbidity), (chronically) ill

people’s continued participation in society, increasing deinstitutionalization and the

growth of cross-sectoral care, as well as the role of technology in maintaining care

recipients’ autonomy, control and independent functioning. These developments

demand new and different competences from the NP.

The NP has definitively 'arrived' in the Dutch healthcare sector. Nevertheless, there is still

a lot of work to be done. She is not yet the obvious partner in the organization of

healthcare in all organizations. V&VN Verpleegkundig Specialisten (V&VN VS)3 does

everything in its power to change this. This requires the commitment of the NP at all

levels: from the clinic to politics. It also calls for the professional group to be connected,

both in the institutions and in networks, and nationally in a powerful professional

association.

Reading guide

Chapter 1 describes the context of the NP as a T-shaped professional with generalist and

specialist skills. The shared competences of NPs according to the CanMEDS-framework

are described in chapter 2. The following chapters describe the specialist competences:

chapter 3 the competences of the NP somatic health care and chapter 4 the competences

of the NP mental health care. These competences are specifically related to the clinical

expertise competency area and describe the competences of the NP somatic health care

3 Section of the professional association of nurses and care-assistants in the Netherlands concerned with the professional interests of Nurse Practitioners.

7

and the NP mental health care in relation to the focus area, the area of expertise, the

spectrum of treatment and the treatment process.

This main document is accompanied by appendices that can be read separately. Appendix

1 relates how this revised professional competency framework has come into being.

Appendix 2 describes developments in the demand for care, supply of care and views on

health. Appendix 3 discusses the development of the NP profession, as well as the

principles of advanced practice nursing. Appendix 4 describes the professional partners

with whom the NP cooperates. Appendix 5 contains explanations of the terms printed in

bold in chapters 1 to 4.

Postscript

The authors have profited from the expertise of the V&VN VS members, as well as from

the input from professional organizations, sector organizations, and education and

research institutions, among others. On behalf of V&VN VS, we would like to thank them

warmly for this.

We are convinced that this professional competency framework, which details the two

specialties somatic health care and mental health care, will prepare the NP well for future

developments in society and in healthcare, so that the NP can exercise her profession for

the benefit of the care recipient and society!

Mr J.D.S. Kappert MSc BN; Chairman of the working group on the Nurse Practitioner’s

professional competency framework

Mrs I.H. de Hoop M ANP M HC&SW, President of V&VN VS

31 January 2019

8

1. The Nurse Practitioner: generalist and specialist

1.1 Introduction

Healthcare professionals should possess a dynamic continuum of competences, tailored

to the wish of care recipients to be capable of functioning in their own living environment

for as long as possible. After all, it is not the disease or the disorder, but the care

recipients’ functioning, resilience and control over one’s life that are increasingly central

to care (Kaljouw & Van Vliet, 2015). The Nurse Practitioner (NP) must also be prepared

for this. In preparation for her future role, this professional competency framework

describes the NP as a generalist and as a specialist. For this purpose, the model of the T-

shaped professional is used. In addition, the NP will be explicitly positioned as an

independent practitioner, in cooperation with other practitioners in the care team, in the

role of coordinating practitioner or co-care provider. Before we discuss the NP

competences, we first describe the core of the discipline.

1.2 The core of the discipline

The NP is an independent practitioner with an independent practice authority. The core

of her competency area consists of offering integrated treatment4 to care recipients

based on clinical reasoning in complex care situations, ensuring continuity and quality of

treatment, and supporting the care recipient’s autonomy, control-taking, self-

management and empowering him or her within the patient journey. The provided

treatment includes both medical and nursing interventions. The NP works from a holistic

perspective. This means that she focuses on the person’s illness and on him/her being ill,

in which approach the human being in his or her context is central. She also focuses on

the consequences of illness and on prevention.

As an independent practitioner within a care team, the NP functions as a coordinating

practitioner or co-care provider. As a coordinating practitioner, she is responsible, in

addition to carrying out part of the treatment, for directing the care process. In this

capacity, she oversees the entire treatment, coordinates the treatment and deploys other

assistance if necessary. As a co-care provider, she is responsible for a specific part of the

treatment.

The NP strives to improve professional standards, the quality of the multidisciplinary care

team and the quality of care, and shows leadership, both in patient care and the further

professionalization of nursing.

4 The treatment offered by the Nurse Practitioner combines nursing and medical interventions. The term ‘treatment’ used in this document is understood to mean both the medical and nursing interventions. Each is defined separately in Annex 5.

9

1.3 The Nurse Practitioner: independent practitioner

The NP is registered in one of the two specialist registers on the basis of the provisions of

article 14 of the BIG Act. By registering in an article 14 specialty it appears that she, as a

nurse, has a special expertise. This expertise concerns the provision of complex nursing

care and/or medical care of a more limited complexity. She has an independent practice

authority in accordance with Article 36 of the BIG Act. This enables her to act as an

independent practitioner. She can reach her full potential if the nursing treatment and

medical treatment are interrelated. The NP enters into an independent treatment

relationship with a care recipient. This is done on the basis of the care recipient’s care

needs so that the care recipient’s autonomy and control-taking is supported and

promoted as much as possible. This requires supporting the care recipient’s self-

management and promoting his or her empowerment. The NP follows the patient

journey. Ethics is the basis for the NP’s actions and treatment provision. Her actions are

characterized by careful consideration, especially when moral dilemmas arise.

It is important here that NPs are always fully responsible for the work they do, whether

as coordinating practitioners or as co-care providers. Among other things, they work

alongside and together with physicians and medical specialists, may function as an

independent practitioner, and may select, carry out and delegate reserved procedures

on the basis of the BIG Act. The latter means: instructing the authorized persons to carry

out these activities.

1.4 The coordinating practitioner

The NP can fulfil the role of coordinating practitioner. In the Meurs Committee report

(2015), this concept is expressed as follows: "The professional who is responsible for

steering the care process of an individual care recipient."

This means that the coordinating practitioner coordinates the care process and is the first

point of contact for the care recipient and his relatives and/or legal representative. If care

is provided by one care provider, this is by definition also the coordinating practitioner.

In the case of multidisciplinary treatment, the coordinating practitioner has a substantial

share in the treatment as such.

Together with the care recipient, the coordinating practitioner draws up the treatment

plan, coordinates the care recipient's treatment with all the care providers involved and

is responsible for the coherence of the entire treatment. This is aimed at agreement by

means of joint decision-making. The coordinating practitioner is not responsible for the

services and interventions carried out by other care providers during the treatment

10

process. The other care providers themselves are fully responsible for this. The

coordinating practitioner is aware of the expertise of the fellow practitioners.

Which care provider acts as the coordinating practitioner in a multidisciplinary setting

depends on the type of treatment and the target group. The NP functions best as a

coordinating practitioner if she performs most of the treatment, and/or if the emphasis

of the treatment is on the consequences of the treatment and illness for the health

experienced by the care recipient, the physical and/or psychological functioning, the

quality of life and the dignity of life.

1.5 The Nurse Practitioner: T-shaped professional

NPs are T-shaped professionals. This means that they have in-depth problem-solving skills

within their own competency area and are also able to interact with other professionals

from other specialties (IfM & IBM, 2008). See figure 1 on page 11 for a graphical

representation of this T.

The vertical part of the T is built of the specialist skills in either the somatic health care or

mental health care specialty, within a focus area (for example specialist medical care or

adult psychiatry) and an area of expertise (for example elderly care or addiction care). In

addition, NPs possess generic competencies allowing to work together with professionals

from other disciplines; the horizontal part of the T. In addition to specialist knowledge, T-

shaped professionals also play an important role in promoting a professional working

environment.

Figure 1 – The Nurse Practitioner: a T-shaped professional (page 11)

12

1.6 Generic competencies

The NP makes integrated use of generic competencies related to: a. diagnosing and treating on the basis of the intended care outcomes:

• the methodical and systematic making of a diagnosis and the selection, organization and provision of nursing and medical treatment

on the basis of clinical reasoning, whereby the professional standard is followed in a substantiated manner or from which a deviation

is substantiated on the basis of evidence-based practice;

• supervising care recipients with a focus on the illness and being ill, in which the individual in his or her context is central. The results

of treatment by the NP relate to maintaining or regaining the health experienced by the care recipient, and his or her physical and/or

psychological functioning, quality of life and dignity of life. The NP anticipates health risks (prevention), and supports the care

recipient’s self-management and empowerment;

b. carrying out scientific research and applying the results:

• assessing the value of the results of scientific research for professional practice;

• initiating, setting up and carrying out scientific research aimed at professional practice;

• participating in knowledge networks;

c. teaching and training:

• supervising, coaching and teaching fellow care providers;

• training (supervising) Nurse Practitioners in training;

• initiating and participating in peer consultation;

d. developing the quality of care:

• initiating, developing and implementing interventions relating to quality of care, innovation and (evidence-based) professionalization

of the working environment, taking into account the interests of the care recipient, the interests of internal and external partners,

and cost-effectiveness aspects;

• participating in quality networks, including suggesting subjects for improvement;

e. showing leadership:

• showing leadership by taking the initiative to increase the quality of care (value-driven care) for the benefit of the individual care

recipient (clinical leadership), the organization and/or the team, or public health and the healthcare system;

• the further professionalization of the NP profession and of nursing.

13

2. The Nurse Practitioner: the shared competency area

2.1 Introduction

The competency area is the field in which the NP somatic health care and the NP mental

health care are professionally autonomous (Terpstra et al., 2015). This means that NPs in

this field can independently give substance to the profession. In these situations, they

independently make effective choices in the care process. They are responsible for this

and can be held responsible for it.

There are two legal specialties: somatic health care and mental health care. The NP

somatic health care independently performs nursing and medical diagnostics and the

resulting treatment, guidance and support of care recipients with physical complaints and

disorders. The NP mental health care independently performs nursing, medical and

psychological diagnostics and carries out the resulting treatment, supervision and

support of care recipients with psychological complaints and/or psychiatric disorders. In

addition, the profession has a generic basis: the shared competency area. The shared

competency area is described in this chapter on the basis of the CanMEDS competency

areas.

2.2 The CanMEDS competences of the NP

The NP, as a T-shaped professional, has a number of defined competences. From the

point of view of uniformity, the description of these competences is ordered according

to seven ‘areas of competency’, also known as 'roles', based on the system of the

Canadian Medical Education Directives for Specialists (CanMEDS) (Frank, Snell &

Sherbino, 2015). These areas are inextricably linked; clinical expertise is central:

treatment based on nursing and medical expertise. This guides all other areas. This is

shown graphically in figure 2 (page 14). The ordering in CanMEDS areas of competency

also forms the basis for the professional competency frameworks of the care assistant,

the (coordinating) nurse5 and of medical specialists. More and more job profiles are also

based on this.

The General Decree of the CSV (2016) and the specific decrees regarding the former five

specialties formed the basis for the description of the competences (CSV 2008a-d; CSV,

2009).

5 In the future, the Bachelor of Nursing registered nurse in the Netherlands will probably be referred to as ‘coordinating nurse’ – as opposed to the ‘nurse’ who has completed vocational education.

14

Figure 2 – The CanMEDS areas of competency of the Nurse Practitioner

15

The areas of competency are the following:

• Clinical expertise: the NP as a practitioner with nursing and medical expertise;

• Communication: the NP as communicator;

• Collaboration: the NP as a collaboration partner;

• Organization: the NP as an organizer of quality of care improvement;

• Health advocacy: the NP as a health advocate;

• Science: the NP as an academic and researcher;

• Professionalism: the NP as a self-confident professional.

2.2.1 Practitioner with nursing and medical expertise

The NP is an independent practitioner who offers integrated nursing and medical

treatment. She enters into an independent treatment relationship with care recipients -

in such a way that the autonomy, control-taking and self-management of the care

recipient are optimally supported and promoted.

For the needs assessment, performance and delegation of reserved procedures for which

the NP has an independent practice authority according to the BIG Act, the NP possesses

competences regarding problem recognition and description, physical examination,

analyzing the problem, additional examination, further analyzing the problem, selecting

(needs assessment) reserved procedures, evaluating the reserved procedure performed,

and reporting and registration (Buijse & Plas, 2007).

The NP makes a methodical and systematic diagnosis. She assesses the need for,

organizes and provides nursing and medical treatment on the basis of clinical reasoning.

In doing so, the professional standard is followed in a substantiated manner, or deviations

are justified on the basis of specific circumstances of the care recipient, or on the basis of

the care recipient's personal wishes (evidence-based practice). Where possible, she

prevents illness or aggravation thereof by anticipating health risks.

The NP’s treatment provision is simple where possible and complex where necessary. The

NP works according to protocols on the one hand, and on the other hand the treatment

is also tailored to the care recipient's needs. The treatment is aimed at maintaining or

regaining the health experienced by the care recipient, the physical and/or psychological

functioning, the quality of life and the dignity of life. It will not always be possible to

improve the care recipient’s health situation and functioning. The health situation and

functioning may also deteriorate. The NP monitors this as well as possible, so that there

is optimal experienced health, functioning, quality of life and dignity in the eyes of the

care recipient, relatives and the social network. The NP supports the self-management of

care recipients and promotes empowerment.

16

Knowledge The Nurse Practitioner has knowledge of:

• the principles of anatomy, physiology, psychology, pathology, psychopathology and

pharmacology, and in-depth knowledge in this area specifically for the own specialty,

focus area and area of expertise;

• the diagnostics, the treatment, the follow-up and the complications of common

disorders on the intersection of the two specialties somatic health care and mental

health care, and in-depth knowledge of these specifically for the own focus area and

the area of expertise in accordance with the state of knowledge, using classification

systems and process-oriented and substantive diagnostic and therapeutic methods,

including the cyclical process of clinical reasoning;

• professional standards, guidelines and protocols that relate to the NP’s line of work

and/or target group.

Skills The Nurse Practitioner is able:

• on the basis of clinical reasoning, to collect targeted information through

observation, independent physical examination and additional diagnostics, to

analyse, interpret and apply this information, make differential diagnoses, make a

diagnosis or probability diagnosis on the basis of classification systems and methods,

and to focus on early risk detection;

• to draw up a treatment plan based on reasoned choices, in which the need of

diagnostic, therapeutic and preventive interventions is assessed, and if relevant

carried out and delegated, including reserved procedures with due observance of

one's own authority and competence, and in which effect and costs are weighed up

and materials and resources are deployed in a responsible way;

• to work according to standards, guidelines and protocols, but may, if necessary,

deviate from these if the situation, the wishes of the care recipient or her own

professional or moral considerations give cause to do so;

• to independently monitor, evaluate and adjust the progress of the treatment;

organize follow-up treatment and aftercare; and independently conclude a

treatment;

• to organize the treatment in the chain in which the care is delivered, by going beyond

the boundaries of her own work unit and organization, if this is in the interests of the

care recipient’s treatment and patient journey;

• to identify complications and act adequately in the event of complications, especially

with regard to common disorders in the specialty and, to a greater extent, within her

own focus area and are of expertise;

17

• to recognize early signs of decompensation (both in the case of physical disorders and

psychological complaints and/or psychiatric disorders) and take appropriate action

or have it taken, especially with regard to common disorders in the specialty and, to

a greater extent, within her own focus area and/or are of expertise.

Attitude The Nurse Practitioner is characterized by:

• working in accordance with the professional code for nurses and care assistants,

supporting and promoting the autonomy of care recipients, and applying the

principles of 'do not harm, do good and justice'6;

• taking into account the wishes and needs of the care recipient and his/her relatives

('deciding together'), the degree of literacy and/or health skills.

2.2.2 Communicator

The NP ensures effective communication with the care recipient, communicates from the

care recipient's perspective and interprets information in the right context. She strives

for an effective treatment relationship, involves the care recipient and his/her family in

the decision-making process and integrates their opinions in the diagnostic process. She

communicates – on the basis of equality – with the care recipient and his/her family about

the diagnostic process, the treatment phase and possible alternatives in such a way that

the expectations of the treatment and the results thereof are realistic and the care

recipient can make a choice on the basis of this. The NP advises on lifestyle and giving

meaning to life, and consults with the care recipient and/or the social network on the

wishes and needs with regard to quality of life. The NP is able to apply Advance Care

Planning.

She uses information and communication technology and helps the care recipient to find

reliable information about diagnosis and treatment. The NP is able to function as a

coordinating practitioner, communicates with various disciplines within and outside her

own organization and ensures adequate reporting and transfer of data.


• various communication theories, such as communication levels (content, procedure,

process), the most important interview techniques in various situations (in any case

anamnesis interviews, bad news interviews, end-of-life interviews [Advance Care

Planning], the principles of motivational interviewing), various ways of influencing

6 Applying these principles is aimed at doing no harm, preventing harm and evil, doing away with evil, and doing and promoting good (autonomy, beneficence & non-maleficence, justice). Any harm must be weighed again other interests. Burdens and benefits should be distributed equally (Beauchamp and Childress, Principles of Biomedical Ethics, Fourth Edition. Oxford. 1994, cited in the Algemeen besluit CSV van 30 mei 2016).

18

and empowering behaviour, the principles of effective consultation and of effective

reporting and transfer;

• the concepts of experienced health, physical and/or psychological functioning,

quality of life and dignity of life and the meaning of these concepts for the request

for help.


• to build and maintain a treatment relationship with a care recipient on the basis of

cooperation and trust created by her expertise;

• to take into account different (cultural) backgrounds, to empathize with care

recipients, relatives and the social network in the different phases of life, health,

illness and death;

• to communicate at content, procedure and process levels and switch smoothly

between these levels, apply conversation techniques appropriate to the care

recipient and the level of communication (level of understanding, background,

physical and psychological condition), give advice and instruct and motivate the care

recipient to make effective treatment choices;

• to implement self-management support strategies and deal with different coping

styles to support care recipients and their families in making treatment decisions,

such as whether or not to continue treatment;

• to deal adequately with aggression, rule-transgressing behaviour and misunderstood

behaviour among care recipients, relatives and the social network;

• to inform and (psychosocially) guide care recipients and their relatives in (complex)

care situations, with regard to, among other things, quality of life in palliative care,

and to make agreements about the roles and commitment of relatives and the social

network;

• to effectively communicate verbally, in writing and digitally about matters concerning

the care recipient (including file management, patient consultation and transfer), and

to ensure continuity of care within the chain by (the organization of) adequate verbal,

written or digital transfers and to make good use of information technology and

communication technology (care technology, eHealth).


• having an eye for the care recipient, his or her loved ones and the social network,

showing empathy and respect, acting as advocate, and adapting communication to

the different phases of life, health, illness and death, the cultural background, the

degree of literacy and/or health skills, and by being aware of the effects of her own

verbal, non-verbal and digital expressions.

19

2.2.3 Collaboration partner

The NP works together with other healthcare professionals on the basis of equality as an

independent practitioner. She carefully and effectively coordinates tasks with them. She

makes clear agreements about the patient groups she sees within her competency area

and - by extension - about performing the needs assessment and delegation of reserved

procedures in these patient groups. Where necessary, she calls on other professionals for

consultation. She provides consultations on the basis of her own expertise, taking into

account the perspective of the care recipient. She provides solicited and unsolicited

advice. If her own expertise is not sufficient, she will refer the patient, while ensuring the

quality and continuity of the treatment.

The NP is the connecting link in the collaboration between medical specialties, between

settings, between disciplines and in chain or network care. She acts as a bridge between

care assistants, nurses, physicians and other disciplines in the care chain. The NP coaches,

supervises and instructs individual nurses or teams of nurses in nursing and medical care

questions and coaches, and supervises and instructs other professionals.

As an independent professional, the NP comes into contact with the care recipient

through direct referral and acts as the coordinating practitioner of individual care

recipients in complex care situations. She is the connecting link and acts as a contact point

for all parties involved.


• the scope of her profession, the position of the profession within the organization,

the scope of her competency area, and the expertise of collaboration partners;

• collaborative processes, such as peer consultation, various frameworks of

collaboration, group and team formation, team roles, group dynamics and giving and

receiving feedback;

• the current standards of care and guidance in the field of (inter-professional)

collaboration.


• to take into account and act on the different perspectives of colleagues, care

recipients and relatives when working together;

• to promote coordination between the members of the multidisciplinary and

interdisciplinary care team, so that the care recipient can benefit optimally from the

total expertise of the team;

20

• to give peer consultations and to act from the perspective of the care recipient to

promote the continuity and quality of treatment, aimed at maintaining or

(re)acquiring the experienced health, physical and/or psychological functioning, the

quality of life and the dignity of the care recipient's life.


• a respectful, collegial and open attitude towards care recipients, relatives, colleagues,

members of the multi-disciplinary and interdisciplinary care team and other

collaboration partners, and stimulating this attitude for herself and others;

• dealing professionally with the different perspectives of colleagues, care recipients

and relatives on the basis of equal collaboration;

• a clear positioning of herself in the multi-disciplinary and interdisciplinary care team,

not afraid of confrontations and differences of opinion, in which she can deal with

differences of opinion and differences in perspective.

2.2.4 Quality of care organizer

The NP is important for quality thinking in healthcare. Her expertise enables her to

monitor the conditions under which the care and support is provided for the line of work

and/or the target group she focuses on.

The NP follows the healthcare-specific and technological developments in her own field

(including ICT and eHealth), translates these into practice and takes into account cost-

effectiveness aspects, the interests of internal and external collaboration partners and

the interests of the care recipients. The NP organizes or reorganizes care processes to

improve the availability and continuity of care, reduce waiting times for the care

recipients and increase cost-effectiveness. In addition, she develops new forms of care,

for example with the help of eHealth, whether or not together with other professionals

and with attention to the recognizability of the nursing profession.

Other tasks in the area of quality of care include (participating in) the development of

evidence-based quality standards and deriving from these standards guidelines and

protocols for the provision of care. The NP also contributes to initiating and interpreting

scientific research aimed at improving the quality of care. To this end, she participates in

quality networks. She implements the quality requirements from legislation and

regulations in the care and treatment process.

21


• the quality frameworks for care and the monitoring of quality of care;

• healthcare systems and policies at home and abroad, the strategic long-term agenda

of the Dutch government, healthcare organizational structures (including her own

professional organization), chain processes and the organization of healthcare in the

own region and in the own organization, as well as quality networks and possible

collaboration partners within and outside the own setting, and is familiar with various

organizational forms and principles from organizational studies;

• management and policy in the healthcare sector, including the financing of care and

the differences between various sectors (acute care, primary care, specialist medical

care, chronic care, mental health care), cost-effectiveness, macro-economic

developments;

• the development of healthcare quality standards, and the guidelines and protocols

derived from these, and their import for the patient journey and the care recipient's

own functioning;

• strategic opportunities for influence.


• to assess whether quality requirements for care in her own workplace are sufficiently

complied with and make recommendations for improvement;

• to translate vision on quality of care into concrete actions aimed at improving the

quality of care;

• to organize or redesign care processes in a process-oriented manner, based on gaps

and changes in the healthcare landscape, and to translate outcomes into indicators;

• to independently take care of (part of) the financing of her own care provision by

means of (billable) registration and DBC healthcare products7 and advise the care

institution on these, and to provide information for and negotiate about the

production within her own institution and with health insurers;

• participate in working groups for the development of quality standards and the

guidelines and protocols derived from them, and to reflect on the significance of

quality standards for the patient journey and her own functioning;

• to make proposals for improvement in the area of quality of care (including care

technology, eHealth, care at a distance), and to be open to innovations in this area.

7 The cost of hospital treatment in the Netherlands is determined by what is known as a Diagnosis-Treatment Combination (DBC in Dutch). This diagnosis treatment combination is also called a DBC healthcare product.

22

Attitude

The Nurse Practitioner is characterized by:

• being open to improvements, changes and innovations in the national healthcare

infrastructure and/or the structure of the organization, awareness of her own

prejudices and judgements in this respect, conscious handling of these, and the ability

to think out-of-the-box;

• promoting, on the basis of national and international trends in the field of care

innovation, the role of eHealth, care at a distance and care technology, taking into

account the patient journey.

2.2.5 Health advocate

The NP helps individual care recipients and groups of care recipients to find their way

around the healthcare system and gain access to the right care at the right time. She also

supports and promotes the care recipient's ability to act as a critical consumer

(empowerment aimed at self-management).

She represents the interests of the individual care recipient and/or specific patient groups

and contributes to the social debate on these issues.

Based on her specific expertise, the NP identifies health risks among individual care

recipients and patient groups – including risks relating to patient safety – at the individual,

organizational and social levels and takes action to influence these. She adheres to

reporting codes, including signals of abuse and neglect, can make these signals

discussable and coach healthcare professionals on these. The NP follows media reports

on insights and trends with regard to her own specialty, the focus area and the area of

expertise.


• the basic principles of epidemiology and of health differences between groups based

on epidemiological data (including incidence, gender, age), socio-economic status

and other contextual factors;

• the principles of self-management, empowerment, lifestyles, prevention and health

education, health and behavioural determinants, social networks, and knows ways of

influencing behaviour and ways to stimulate healthy behaviour;

• social trends within target groups, and is aware of cultures, culture-related views on

health and culture-related health problems and the influence of these views on the

request for help and the provision of care.

23


• to identify health risks (individually, and at the organizational and social levels) and

interpret and incorporate the results of epidemiological research in the treatment;

• to support the self-management and social network of a care recipient, promote

empowerment, advise on lifestyle changes or continuation of therapy, and has

outreach care and interference care skills;

• to carry out interventions concerning individual and collective prevention and health

education, and to develop policies and interventions aimed at prevention and early

detection;

• to promote changes in the care delivery on the basis of social developments, to

identify factors that pose a threat to care recipients and/or specific groups, and to

propose and implement policy in the area of prevention.


• contributing to patient safety at both the level of the individual care recipient and the

level of the organization and/or care chain.

2.2.6 Academic and researcher

The NP has a reflective and learning attitude and thereby acts as a role model for others.

She is focused on sharing knowledge and contributes to the expertise of colleagues and

other healthcare professionals. The NP plays an active role in training future

professionals, in practice and at universities of applied sciences. This is part of the NP’s

professional leadership role8.

The NP is aware of recent scientific developments within her own specialty, focus area

and area of expertise, and critically assesses scientific information. She promotes the

development and implementation of knowledge and expertise within her own specialty,

focus area and area of expertise. She stimulates the expansion of knowledge within her

specialty and her focus area and area of expertise by initiating, setting up and carrying

out monodisciplinary or multidisciplinary scientific research or by participating in

research integrated into patient care.

She translates scientific results into professional practice and participates in the

development of multidisciplinary guidelines. She publishes and collaborates in scientific

and non-scientific publications, and participates in knowledge networks.

8 In her doctoral thesis, Dr Ter Maten-Speksnijder (2016) recommends that Nurse Practitioners should also pay attention to research, education and leadership.

24


• the principles of evidence-based practice and of best practices;

• various methods for carrying out (mono- and multidisciplinary) scientific research;

• the various knowledge networks within her own specialty, focus area and area of

expertise;

• the didactics of workplace learning, coaching, reflective practice (supervision, peer-

to-peer learning and peer consultation), and of learning principles, guidance and

instruction methods, and is aware of applications in the field of knowledge

development and sharing and of the concept of lifelong learning;

• ethics and healthcare ethics and methodologies for dealing with moral dilemmas.


• to retrieve the results of scientific research, to understand these, to assess their value

and to apply these in practice;

• to make a connection between problems in professional practice and science, and to

initiate, set up and carry out scientific research in response to a research question

derived from professional practice or gaps in the scientific knowledge base within her

own area of expertise;

• to develop new interventions based on research results;

• to promote the development and deepening of scientific expertise by means of

scientific research and innovation projects;

• to participate in knowledge networks aimed at her own specialty, focus area and area

of expertise;

• to coach, supervise and teach fellow care providers, such as care assistants, nurses

(among whom Nurse Practitioners in training) and physicians, and to transfer,

delegate, advise and give feedback on their actions and professional behaviour;

• to act as trainer of Nurse Practitioners in training.

25


• a reflective ability that is expressed in professional practice as an independent

practitioner;

• a critical ability that is expressed in the assessment of new knowledge, research

results and new procedures;

• promoting the expertise of students, colleagues, care recipients and other parties

involved in healthcare, in which she plays a pioneering role and serves as a role model

for both prospective and qualified nurses and coordinating nurses, whether or not in

training to become a Nurse Practitioner.

2.2.7 Self-confident professional

The NP is a self-confident professional who steers her profession and works continuously

on her personal and professional development. She provides high-quality patient care in

an honest, sincere and committed manner, with attention to the care recipient’s

integrity, autonomy and control-taking.

The NP makes her added value clear. Through her daily functioning, she shows that she

is worthy of the trust of the care recipient and his or her environment. The NP is a valuable

professional within the organization. She is aware of the added value of their own care

provision and negotiates about this if necessary – within the institution or with health

insurers.

The NP is accountable for his or her own professional actions. She often works in a

multidisciplinary context, but has the opportunity to practice independently. The NP

knows the limits of her own competences and makes clear agreements with other

professionals about the division of tasks, responsibilities and coordination.

The NP follows accredited continuing education and training, both nationally and

internationally, aimed at treatment on the basis of nursing and medical expertise as well

as in other areas of competency. The quality of the care she provides remains high

through peer evaluation with (fellow) NPs or other professionals with whom she

cooperates.

The NP works on the profiling and further professionalization of the specialty and

participates in professional and interest groups. She has an innovative and proactive

professional attitude. She actively contributes to the policy of care organizations, for

example by serving on nursing advisory councils or professional organization. The NP

solidifies herself in professional networks and shows leadership at all levels.

The NP takes care of her own health as an employee and sets her own limits.

26


• the state of the art of the competency area in which she works (including current

guidelines and professional standards) and of current themes and developments in

her own area of expertise;

• the vision of the profession on good care, social developments, the role of NPs and

leadership;

• the legislation and regulations that apply to the professional practice, including those

regarding independent treatment responsibility, coordination, patient safety, quality

requirements and information transfer.


• to represent and position the own professional group within and outside her

organization and to substantiate the added value of her own actions in terms of the

available evidence-based practice and cost-effectiveness;

• to contribute to the state of the art of her own competency area by means of

scientific research, care innovation and quality of care interventions;

• to work independently and proactively on the promotion and development of her

expertise, including for the purpose of re-registration as a NP, and to establish and

maintain the development and exchange of peer expertise and knowledge;

• to read and interpret professional literature, to follow (accredited) training and

attend congresses and to be subject of peer evaluation;

• to position herself as an independent practitioner in the role of coordinating

practitioner and/or co-care provider, and herein show professional and personal

leadership;

• to value and critically approach her own functioning, to make her own functioning

and experiences discussable with colleagues and care recipients and to integrate

feedback on these into her actions, and to develop through feedback, self-reflection

and self-assessment and to discuss ethical and meaning issues with colleagues and

care recipients;

• setting priorities and finding a balance between all aspects of the job: patient care,

scientific research, teaching and training, quality of care and leadership;

• to find a balance in her work, aimed at preventing personal health problems as a

result of a disturbed balance between professional capabilities and workload, both

within and outside the professional practice, where necessary acknowledging her

limits.

27


• acting as a role model for care assistants and (coordinating) nurses, being an

ambassador of the profession;

• acting within the limits of her own expertise and taking responsibility for and being

accountable for her care-related actions;

• acting in accordance with the nursing professional code and legislation and

regulations, observing rules of conduct that are part of the professional

responsibility, and being able to deal with the responsibilities of an independent

practitioner.

Figure 3 – Focus areas, areas of expertise and spectrum of treatment of the NP somatic health

care and the NP mental health care (page 28)

29

3. The Nurse Practitioner somatic health care

3.1 Introduction

In this chapter we describe the competency area of the NP somatic health care: her working

method, the various focus areas, the areas of expertise, the spectrum of treatment and the

role as a coordinating practitioner. Figure 3 (page 28) illustrates the relationship between

focus areas, areas of expertise and the spectrum of treatment.

3.2 Competency area of the NP somatic health care

The competency area of the NP somatic health care includes: independently performing

nursing and medical diagnostics and the resulting treatment, supervising and supporting

care recipients with physical complaints and disorders. The care she provides can cover the

entire spectrum of prevention, treatment, supervision and support.

A physical condition arises from various biomedical factors, in which psychological and social

factors may also play a role (biopsychosocial model) (WHO, 2001). Functional limitations

may arise from the physical condition. The NP somatic health care works from the

perspective of the care recipient and his or her environment to prevent, eliminate or make

manageable complaints and dysfunctions as much as possible. If necessary, support is

provided to the care recipient's social network (such as family members and others closely

involved).

If other healthcare professionals are involved in the care provision in addition to the NP

somatic health care, the NP somatic health care can take responsibility for the integrality

and coordination of the treatment process. The NP somatic health care is then the first point

of contact for all parties involved, including the care recipient and his/her relatives and/or

legal representative. If this is important for the integral treatment of the care recipient, a

form of task substitution will take place in which the NP somatic health care applies medical

treatments in addition to nursing treatments. The NP somatic health care is competent and

employable throughout the entire field of somatic health care insofar as physical complaints

and disorders are dominant in the request for help.

Each NP somatic health care has a generic basis in somatic health care, and concentrates on

an area of expertise within a focus area. Areas of expertise are not regulated in the BIG Act.

In practice, there is a large and dynamic number of areas of expertise. Examples of areas of

expertise are pain, complex wound care, incontinence, oncology, cardiology, dermatology,

neonatology, mental disability care, general practitioner care, ambulance care, emergency

care, elderly care, youth health care and palliative care. Treatment within the focus area and

are of expertise takes place within a diverse spectrum of treatment.

30

3.3 Method of working

The NP somatic health care is an independently authorized practitioner. This implies that

the NP somatic health care is able:

• to carry out, manage, or delegate the entire process of diagnostics, needs

assessment, treatment, referral, transfer and discharge and to independently make

(final) decisions;

• to enter into independent treatment relationships, delegate treatments and, where

necessary, make use of the expertise of fellow specialists from adjacent disciplines

within and outside the somatic health care sector;

• to make well-founded use of current guidelines and standards, the latest scientific

evidence, and of professional networks, expertise by experience and the care

recipient’s social network;

• to contribute to the use and development of evidence-based practice.

In personalized diagnostics, the NP somatic health care uses diagnostic frameworks such as

the International Classification of Diseases and Related Health Problems (ICD-10), the

International Classification of Functioning, Disability and Health (ICF) and the Nursing

Diagnosis Classification (NANDA). In carrying out the treatment, the NP somatic health care

uses medical and nursing therapeutic frameworks such as standards, guidelines, the Nursing

Outcomes Classification (NOC) and the Nursing Interventions Classification (NIC). Treatment

is focused on the care recipient’s health and daily functioning as well as improved quality of

life and dignity of life. In her treatment, the NP somatic health care strives for optimum

autonomy of the care recipient, making optimum use of the possibilities offered by the social

environment and technology.

3.4 Focus areas, areas of expertise and spectrum of treatment

The NP somatic health care is competent and deployable in the entire field of somatic health

care, and in the field of mental health care insofar as physical complaints and disorders are

dominant in the demand for help9. This does not alter the fact that additional expertise is

required. A distinction can be made between focus areas, areas of expertise and the

spectrum of treatment.

In her professional practice, the NP somatic health care takes account of the integration of

care that exceeds the focus areas and areas of expertise in the somatic health care sector.

As a result, she plays a conscious role in the connection between professionals, for example

9 There is overlap between the somatic health care and mental health care sectors regarding the concept of morbidity. The NP somatic health care focuses on physical complaints, and on psychiatric disorders insofar these concern comorbidity of a physical condition or more severe chronic physical functional disabilities as a result of the psychiatric disorder.

31

between specialist medical care and primary care. Her professional practice is not limited to

traditional healthcare domains.

Focus areas

Various focus areas can be distinguished according to the currently common sectors in which

the NP somatic health care exercises her expertise:

• acute care;

• primary care;

• specialist medical care;

• chronic care.

Acute care Acute care is characterized by life-threatening vital function disorders, often due to an acute

disturbance in the homeostasis as a result of an accident or a previous medical intervention,

as a result of comorbidity or due to a sudden physical disorder. This is where the focus of

care lies. The NP somatic health care within this focus area works for example at a regional

ambulance care institution or an emergency department of a hospital.

Primary care Primary care concerns the interface between preventive care and acute care, but also the

treatment of chronic disorders, within the care recipient’s social context. The emphasis is

often on health education and prevention. This includes the health of employees of

companies. In order to cope with requests for help, collaboration plays a central role within

the general practitioners' practice and the general practitioners' service, for example in the

connection with secondary emergency care, but also in the connection with the municipality

and the social domain. The NP knows the social map, the other stakeholders, and forms

connections between the various parties so that the care recipient receives the best care. A

current development is the transfer of specialist medical care from hospitals to primary care

and the enhanced collaboration between specialist medical care and primary care

(integrated primary/secondary health care), which enables increasingly complex treatments

in the home situation. The field of work is therefore in transition. There is low-threshold

contact with acute care, medical specialist care, chronic care and mental health care. The

NP somatic health care within this focus area works at general practitioners' practices,

health centers or general practitioners' services, but also at municipal health services, home

care organizations or work-related care organizations.

Specialist medical care In the area of specialist medical care, the focus of care is on the diagnosis and treatment of

physical disorders of various kinds, as well as on the early recognition of side effects and

complications and the diagnosis and treatment of these. In addition, the psychosocial

counseling of care recipients and relatives plays an important role in often far-reaching

32

physical disorders. A current development is the transfer of specialist medical care from

hospitals to primary care and the greater collaboration between specialist medical care and

primary care (integrated primary/secondary health care), which enables increasingly

complex treatments in the home situation. The field of work is therefore in transition. There

is easily accessible contact with professionals in primary care and chronic care. The NP

somatic health care within this focus area works in (academic) hospitals or in independent

treatment centers. Chronic care In the area of chronic care, the focus of care is on the quality of life and the dignity of life in

chronic treatment. Diagnostics and the treatment of physical disorders are mainly aimed at

this, although everyday physical disorders are also treated curatively. However, this is often

chronic treatment, which can take many years. The NP somatic health care has an important

guiding role here: she supports the care recipient and his or her loved ones in realizing that

a shift in balance between health and disease is underway. The focus of treatment and

counseling often ultimately lies on palliative care. The NP somatic health care within this

focus area is active in elderly care, for example within nursing home care institutions, or

intellectual disability care. Areas of expertise

The area of expertise of the NP somatic health care encompasses the whole of specific

knowledge, skills and attitude to provide optimal care to specific patient groups. This specific

expertise complements the common expertise and competences within the focus area. In the broad somatic health care sector, the NP somatic health care develops in-depth

expertise in nursing and medical treatment for a specific patient group or groups. A patient

group is characterized by a certain health problem, a cluster of medical conditions, a life

phase, a setting or a vision on care. The areas of expertise are characterized by the intrusive nature and high prevalence of the

health issues, and require specific knowledge and expertise. Over the years, areas of

expertise will develop and inevitably change. To illustrate this, we give a number of examples of areas of expertise:

• health problems: pain, complex wound care, incontinence;

• clusters of medical conditions: oncology, cardiology, dermatology, neonatology,

mental health care for the disabled;

• settings: general practitioner care, ambulance care, emergency care;

• life phase: elderly care, youth health care, palliative care.

Some areas of expertise have already been further developed. These are described below.

33

General practitioner care

The NP somatic health care in general practitioner care treats patient groups at various

stages of life and within the care recipients’ social systems. She focuses on health

information and prevention as well as diagnostics and treatment of everyday physical

disorders. If necessary, she refers to specialist medical care and/or other sectors. She comes

into contact with both acute care and chronic care and psychological complaints. She deals

with common complaints, but is also involved in the home functioning of care recipients

who have undergone or undergo extensive specialist medical treatment. She also treats care

recipients in the palliative phase.

Oncology The NP somatic health care in oncology is a practitioner in the care network of cancer

patients. She has specialist knowledge of oncogenesis, cancer diagnostics and oncolytic

treatment (including treatment with antineoplastic agents), as well as palliative care when

curative treatment options are exhausted. Her expertise lies in connecting the mostly

invasive curative treatment with quality of life. She is also able to diagnose and treat the

side effects and complications of the treatment. Her work is also emphatically focused on

the psychosocial functioning of cancer patients. If necessary, she will use supportive

(psychological) treatments and/or refer to mental health care. She is also the link between

specialist medical care and primary care in the care recipient’s network.

Elderly care The NP somatic health care in elderly care – either chronic elderly care or geriatric

rehabilitation care – focuses on the physical disorders associated with ageing, and on

preserving the quality and dignity of life of ageing people. In this context, she diagnoses

somatic and psychogeriatric problems, and offers both curative treatment of common

physical disorders and palliative treatment. She assists care recipients and their families in

the pursuit of optimum quality of life and dignity of life in the changing context of life, health,

illness and death that occurs in old age.

Spectrum of treatment

The following components of the spectrum of treatment are distinguished within the focus

areas and areas of expertise:

• preventive treatment;

• emergency treatment;

• intensive treatment;

• chronic treatment;

• palliative treatment.

34

Preventive treatment The primary and secondary prevention of physical disorders by identifying (possible) health

threatening factors. In prevention, promoting healthy behaviour is paramount, and the NP

somatic health care applies the principles of health information and education.

Emergency treatment The treatment of acute health-threatening and/or life-threatening physical disorders is in

the foreground. Treatment by the NP somatic health care depends heavily on medical

diagnostics and treatment.

Intensive treatment The treatment of the disease and the consequences of the disease for the care recipient’s

immediate functioning are central. The integrated nursing and medical treatment provided

by the NP somatic health care depends heavily on medical diagnostics and treatment.

Chronic treatment The ongoing treatment of physical disorders by the NP somatic health care is central with a

focus on tertiary prevention, dealing with disorders, limitations and disabilities resulting

from one or more comorbidities, and promoting sustained social participation. Nursing

treatment plays an important role; medical and multidisciplinary treatments are mainly used

to support this.

Palliative treatment Treatment for people with a life-threatening condition or frailty, for example at the

approaching end of life. The NP somatic health care focuses on maintaining or improving the

quality and dignity of life in the final stage of life, in constant dialogue and coordination with

the care recipient, relatives and/or legal representative and the social network. Medical and

nursing interventions are implemented for the benefit of the quality and dignity of life.

3.5 The NP somatic health care as coordinating practitioner

The NP somatic health care can coordinate the care for or the supervision of part or the

entire patient journey. If she carries out most of the treatment, or if the emphasis of the

treatment is on the consequences of the treatment and illness for the experienced health,

physical and/or psychological functioning, quality of life and dignity of life, she has the role

of coordinating practitioner. She shall consult another practitioner, for example a medical

specialist, in the event of requests for help that lie outside her expertise.

35

3.6 The NP somatic health care as co-care provider

The NP somatic health care may be asked to take on a specific part of the treatment within

the framework of a larger treatment program. This specific part may consist of more limited

complex, routine medical treatments, or complex nursing interventions within a care

process. She will then be a co-care provider.

3.7 Specific competences of the NP somatic health care

In addition to the aforementioned shared competences of the NP, the NP somatic health

care differs from the NP mental health care in the nature of the specialty-related

competences in the clinical expertise competency area. This section describes the specific

competences of the NP somatic health care, first in relation to the focus area, the area of

expertise and the spectrum of treatment, and then in relation to the treatment process.

3.7.1 Competences regarding the focus area, area of expertise and spectrum of treatment

Knowledge The NP somatic health care has knowledge of:

• The diagnostic, therapeutic and preventive arsenal for common disorders in the

somatic health care sector;

• The diagnostic, therapeutic and preventive arsenal with regard to common disorders

within one or more of the following focus areas:

o acute care;

o primary care;

o specialist medical care;

o chronic care;

• the diagnostic, therapeutic and preventive arsenal with regard to common disorders

within one or more areas of expertise10, possibly including the following areas of

expertise:

o general practitioner care;

o oncology;

o elderly care.

10 Several areas of expertise can be distinguished, in line with the specific patient population(s) the NP somatic health care works with, and on the basis of which she has gained further specific expertise during her theoretical and practice training, re-training, and refresher courses.

36

Skills The NP somatic health care is able:

• to provide somatic health care in an effective, efficient and ethically responsible

manner within the aforementioned focus areas and areas of expertise;

• to act within the various components of the spectrum of treatment:

o preventive treatment;

o emergency treatment;

o intensive treatment;

o chronic treatment;

o palliative treatment.

• to apply the diagnostic, therapeutic and preventive arsenal – where possible

evidence-based – using a combination of nursing and medical methodologies and

possibly methodologies from other disciplines such as psychology11;

• to independently select, carry out and delegate reserved procedures12.

Attitude The NP somatic health care is characterized by:

• the linking of nursing and medical treatment for the benefit of the care recipient’s

experienced health, physical and/or psychological functioning, quality and dignity of

life.

3.7.2 Competences regarding the treatment process

The clinical expertise competency area includes specific competences allowing the NP

somatic health care to act as an independent practitioner within the focus area, the

expertise area and the spectrum of treatment. The description below follows the treatment

process.

The NP somatic health care is able:

• to purposefully collect information:

o knows the principles of taking a medical history and heteroanamnesis in

somatic health care practice;

o can apply these principles in the assessment of care recipients;

11 This concerns knowledge of psychologic interventions that may be implemented for the psychosocial support of care recipients. 12 On the basis of the current reserved procedures granted to the ‘acute care for somatic conditions NP’ and the ‘intensive care for somatic conditions NP, the NP somatic health care is expected to be able to independently select, implement and delegate the following reserved procedures in accordance with legislation and regulations: the performance of surgical procedures, the performance of endoscopies, the performance of catheterisations, the giving of injections, the performance of punctures, the performance of elective cardioversion, the application of defibrillation and the prescription of prescription drugs as referred to in Article 1, first paragraph, part s, of the Medicines Act.

37

• to select and carry out diagnostic interventions:

o knows the principles of physical examination in somatic health care practice

and specifically within the focus area and area of expertise;

o can perform physical examination in somatic health care practice and

specifically within the focus area and area of expertise;

o is familiar with the common additional examination techniques (including

imaging techniques and laboratory tests) in somatic health care practice and


o can apply these examination techniques in somatic health care practice and

specifically within the focus area and the area of expertise;

• to make a differential diagnosis based on clinical reasoning and to make the right

decisions:

o is familiar with the principles of clinical reasoning and differential diagnosis

in somatic health care practice and specifically within the focus area and the

area of expertise;

o is able to make a differential diagnosis in somatic health care practice and


• to select and carry out therapeutic interventions:

o knows the effects (pharmacodynamics and pharmacokinetics), side effects,

contraindications and interactions of commonly used drugs within somatic

health care;

o has specialist knowledge of the effects (pharmacodynamics and

pharmacokinetics), side effects, contraindications and interactions of drugs

in the focus area and area of expertise;

o is competent to prescribe medicines in somatic health care practice,

specifically within the focus area and the area of expertise;

o is familiar with the principles of forms of medical treatment in somatic health

care practice and specifically within the focus area and the area of expertise

(including reserved procedures such as prescribing prescription drugs, as well

as psychological interventions);

o can correctly apply these forms of treatment in the appropriate context of

the spectrum of treatment within the focus area and area of expertise;

• to evaluate whether the objectives set have been achieved:

o knows the principles of referral to other specialists in somatic health care

practice;

o has specialist knowledge of referral to other specialists within the focus area

and area of expertise, including referral to mental health care;

38

o can adequately refer care recipients in somatic health care practice and

mental health care practice, specifically for the own focus area and area of

expertise;

o has knowledge of principles of transfer of care to other somatic health care

providers and follows the patient journey;

o can adequately transfer care to other healthcare providers and follows the

patient journey;

o has knowledge of principles of follow-up and discharge specifically for the

focus area and area of expertise;

o can adequately follow up the request for help and/or terminate the

treatment;

o can determine a natural death and/or refer to the municipal coroner in case

of suspicion of a non-natural death;

• directing the treatment and the care process:

o knows the principles of coordinating the treatment and the entire care

process;

o can function as an independent practitioner and, if possible, if the patient

journey makes this desirable, as a coordinating practitioner.

39

4. The Nurse Practitioner mental health care

4.1 Introduction

In this chapter we describe the competency area of the NP mental health care: her working

method, the various focus areas, the areas of expertise, the spectrum of treatment and the

role as a coordinating practitioner. Figure 3 (page 28) illustrates the relationship between

focus areas, areas of expertise and the spectrum of treatment.

4.2 Competency area of the NP mental health care

The competency area of the NP mental health care includes: the independent performance

of nursing and medical diagnostics and the resulting treatment, supervision and support of

care recipients with psychological complaints and/or psychiatric disorders.

The treatment by the NP mental health care focuses primarily on the consequences of the

psychiatric disorder and/or the limitations in the (inter)personal functioning within complex

care situations. If other care professionals are also involved in the care, the NP mental health

care can bear responsibility for the integrality and coordination of the treatment process13.

The NP mental health care is then the first point of contact for all parties involved, including

the care recipient and his or her relatives and/or legal representative. If this is important for

the integral treatment of the care recipient, a form of task substitution will take place. The

NP mental health care integrates medical-psychiatric treatment forms such as prescribing

prescription drugs and also psychotherapeutic treatment forms. Continuous attention to the

prevention of psychological complaints and psychiatric disorders, medicalization and

stigmatization (from the perspective of the care recipient, the care provider and society) is

necessary. The NP mental health care is competent and can be employed in the entire field

of mental health care, but also in the somatic health care sector if psychological complaints

and psychiatric disorders play a role in the request for help.

Treatment within the focus area and area of expertise takes place within a diverse spectrum

of treatment.

13 See also the role of coordinating practitioner as specified in the Dutch model quality charter for mental health care (Model Kwaliteitsstatuut GGZ, 2016).

40

4.3 Method of working

The NP mental health care is an independently authorized practitioner. This implies that

she is able:

• to carry out, manage, or delegate the entire process of diagnostics, needs

assessment, treatment, referral, transfer and discharge and to make (final) decisions

independently;

• to enter into independent treatment relationships, delegate treatments and, where

necessary, make use of the expertise of fellow specialists from adjacent disciplines

within and outside the mental health care sector;

• to make well-founded use of current guidelines and standards, the latest scientific

evidence, and of professional networks, expertise by experience and the care

recipient’s social network;

• to contribute to the use and development of evidence-based practice.

The NP mental health care is active in settings where multiple-complex and/or single-

complex care situations are paramount. Multiple-complex care situations will often involve

problems in several areas of life where major health risks are at stake. Due to a low degree

of predictability of the course of the disease and the treatment effect, the treatment and

interventions must be continuously adjusted on the basis of the current situation and further

diagnostics.

In single-complex care situations, on the other hand, there is an easily predictable course of

illness with manageable health risks, in which protocol-based treatments and/or treatments

of limited quantitative scope are sufficient (Kaljouw & Van Vliet, 2015).

The most important therapeutic instrument is the NP mental health care as a practitioner

herself. She continually reflects on her own actions and attitude. She is able to recognize,

investigate and use transference and countertransference to establish and maintain a

therapeutic alliance – aimed at achieving the treatment goal. Validation of this therapeutic

instrument requires sustained effort.

In her personalized diagnostics, the NP mental health care uses classification systems, such

as the DSM-5, ICF and NANDA, which can also be used to map the care recipient's request

for help. In carrying out the treatment, the NP mental health care uses nursing interventions

aimed at the intended results of the treatment as classified in the NIC and the NOC. The

results of the treatment mainly concern daily functioning, recovery and improving the

quality of life.

The NP mental health care also uses psychodynamic, (cognitive) behavioural therapy, group

dynamics, environmental therapy and systemic interventions to influence the cognitions,

moods, behaviour and attitudes of the care recipient and his or her system. Where necessary

41

and indicated, the care recipient’s mentalizing ability is promoted. Pharmacotherapeutic

interventions or the prescription of prescription drugs are carried out from the medical

domain when this facilitates integral treatment. In the treatment, the NP mental health care

strives for optimum autonomy of the care recipient, making optimum use of the possibilities

offered by the environment and the technology.

4.4 Focus areas, areas of expertise and spectrum of treatment

The NP mental health care is competent and can be used in the entire field of mental health

care, and in the field of somatic health care insofar as psychological complaints or psychiatric

disorders are dominant in the demand for help14. This does not alter the fact that additional

expertise is required. A distinction can be made between focus areas, areas of expertise and

the spectrum of treatment.

In her professional practice, the NP mental health care takes into account the integration of

care that exceeds the focus areas and the areas of expertise in the mental health care sector.

As a result, she plays a conscious role in the connection between disciplines, for example

between mental health care and somatic health care. Her professional practice is not limited

to traditional healthcare domains.

Focus areas The focus areas are developmental psychologically oriented. These are:

• child and adolescent psychiatry;

• adult psychiatry;

• gerontopsychiatry.

Child and youth psychiatry The focus area of child and youth psychiatry consists of both youth mental health care and

youth care. Youth care includes: ambulatory youth assistance, foster care, youth care plus,

stay in a youth institution, youth protection, youth rehabilitation and youth care for young

people with a disability. The support within this focus area focuses on children and young

people who, due to their psychological complaints, developmental disorder and/or

psychiatric disorder, show psychological suffering, serious problem behavior and/or are

restricted in their social and school functioning, which has a negative influence on the

development towards adulthood and the quality of life. An explicit aspect of the focus area

is the (social and pedagogical) environment of the children and young people; it is strived

for to offer accessible and unambiguous care as much as possible in the immediate living

environment. Treatment and/or (pedagogical) support is offered to parents and/or

14 There is overlap between the somatic healthcare and mental healthcare sectors regarding the concept of morbidity. The NP mental health care focuses on somatic conditions insofar these concern comorbidity or somatoform disorders.

42

educators and schools in order to remove as much as possible the obstacles that stand in

the way of a balanced development towards adulthood. The care can also focus on situations

in which the upbringing threatens to become so problematic that parents/educators can no

longer cope and/or the safety of the child or the young person is at stake.

Adult psychiatry The focus area of adult psychiatry concerns the care of adults who suffer psychologically

and/or are restricted in their social and societal functioning due to their psychological

complaints and psychiatric disorders, which has a negative influence on the quality of life.

Care for adults is increasingly taking shape in a social context, with outpatient treatment

taking precedence. Focal treatment is aimed at resolving the complaints. An integrated

treatment is aimed at improving daily functioning; the emphasis is on recovery support,

rehabilitation and social reintegration.

Gerontopsychiatry The focus area of gerontopsychiatry is characterized by the senium-related combination of

somatic, cognitive and psychiatric disorders, the changed pharmacokinetics and dynamics,

the diminishing functioning in daily life, and the social embedding and diminishing flexibility

(vulnerability). The double ageing of the population, the tendency for older people to live

longer at home and the fact that society is increasingly individualizing play a role in this. Here

too, ambulatory treatment or care prevails. Interventions are focused on maintaining

function and prognostic factors of greater demand for care.

Areas of expertise The NP mental health care has knowledge and skills in the treatment of general psychiatric

conditions such as psychoses, mood disorders, personality disorders and traumatic

experiences. In addition, there are areas of expertise that often go hand in hand with the

aforementioned conditions. The areas of expertise are characterised by the intrusive nature

and high prevalence of the problem, and require specific knowledge and expertise. Over the

years, areas of expertise will develop and inevitably change. Several clusters of areas of

expertise that have existed for some time can currently be distinguished to which knowledge

and skills are tailored. Care recipients may have to deal with problems from different areas

of expertise:

• mild intellectual disabilities with psychiatric comorbidity;

• transcultural psychiatry;

• forensic psychiatry;

• addiction care.

43

Mild intellectual disabilities with psychiatric comorbidity In mental health care, mild intellectual disabilities among care recipients are often not

recognized. The disabilities are often expressed in a disharmonious intelligence profile, and

cognitive, social and emotional limitations that lead to functional problems. People with a

mild intellectual disability have problems with 'being able' as well as problems with 'being

able to cope', which leads to an overload. This also causes problems in social functioning and

behavior that interfere with or lead to psychiatric disorders or addiction problems. People

with a mild intellectual disability have a higher comorbidity with psychiatric disorders and/or

addiction.

Transcultural psychiatry Transcultural psychiatry is characterized by cultural-sensitive work. The treatment of care

recipients takes account of social and cross-cultural diversity (diversity in culture, gender,

religion, spirituality and sexuality). The NP mental health care is aware that symptoms may

present differently. In a transcultural context, other forms of human conduct and other

expectations with regard to the course and results of the treatment are also taken into

account. This requires a judgement-free connection with the care recipient and his or her

background and environment.

Forensic psychiatry Forensic psychiatry includes outpatient, semi-institutional and inpatient treatment for

people who have an increased risk of criminal behavior associated with psychiatric disorders,

addiction or mild intellectual disabilities. The treatment is aimed at risk management with a

safe society as the primary goal. Psychiatric and medical care and treatment are offered

secondarily. Often there is involuntary treatment, imposed as a punitive measure. The

treatment takes place during or after the execution of the sentence for an offence, or after

the display of criminal behavior. Forensic psychiatric treatment is offered in various settings.

Consultation is increasingly being provided to colleagues in the regular mental health care

sector. Forensic psychiatry is characterized by a close relationship with the judiciary.

Addiction care Categorical addiction care includes ambulatory, semi-institutional and inpatient treatment

and counseling to people with an addiction disorder with regard to substances and behavior

(alcohol, drugs, medicines, food, games, sex, gambling and internet). Addiction is seen as a

syndrome with a growing chronicity, characterized by craving, tolerance and loss of control.

This syndrome ultimately leads to a reduced autonomy in thinking, feeling and acting.

The addiction treatments focus on the addiction disorder itself and on disorders related to

the use of the substance. Common disorders are psychotic disorders, anxiety and mood

disorders, sleep disorders, sexual dysfunctions and neurocognitive disorders. The

44

diagnostics and treatment are aimed at a combination of the biological, psychological and

social functioning and the breaking through of the cause-effect cycles that maintain the

addiction and the additional syndromes. The treatment often has three objectives:

• become and remain abstinent;

• reduction of substance use and/or addiction behavior and improvement and/or

stabilization of the quality of life;

• palliative care and reduction of nuisance for the care recipient and his environment.

Care for people with an addiction problem is not limited to 'addiction care institutions'; other

institutions also provide support to people with an addiction problem. Examples are: general

practitioners' practices, regular mental health institutions, the prison system, mild

intellectual disability care, municipal health services, social care, district teams, and also

somatic health care. Addiction care workers closely collaborate with these institutions and

teams, offering support in the form of expertise building or intervening in the teams in

complex situations.

Spectrum of treatment The following components of the spectrum of treatment are distinguished within the focus

areas and areas of expertise:

• clinical treatment;

• ambulatory treatment;

• emergency treatment;

• consultative psychiatry;

• interference care.

Clinical treatment Clinical treatment is understood to mean: care and treatment involving overnight stay. This

can be understood as institutional or semi-institutional care. There is a need to continuously

monitor, stimulate, support or take over the care recipient’s daily functioning. Semi-

institutional care includes forms of protected housing. Clinical treatment is based on

multidisciplinary collaboration.

Outpatient treatment In outpatient treatment, care and treatment are transferred to the place where the care

recipient is located, or to the outpatient clinic; the care recipient then comes to the NP

mental health care. Outpatient treatment explicitly requires attention for the care

recipient’s immediate surroundings. The treatment can be multidisciplinary or

monodisciplinary.

45

Emergency treatment Emergency treatment is characterized by crisis intervention within 24 hours after

registration. This concerns support to people in acute psychological or psychiatric distress -

24 hours a day and 7 days a week. A psychiatric crisis involves integral diagnostics and the

deployment of de-escalating interventions. This means that in addition to psychopathology,

also the somatic and social context are assessed. There may be delirium, dementia,

psychosis, dissociation, risk of suicide and aggression. Emergency treatment is called upon

when people from their psychological problems call for care or disturb public order. Triage

is important here: estimating the risk of suicide and of physical or material damage, as well

as the use of interventions, such as assessing the need of admission, prescribing intervention

medication, or activating the social network to deal with the crisis. In addition to an

intellectual and emotional effort, the NP mental health care is expected to be highly stress-

resistant.

Consultative psychiatry Consultative psychiatry is about carrying out psychiatric consultations and offering

consultation. In a psychiatric consultation, the NP mental health care is deployed to

diagnose, treat or give treatment advice aimed at a specific psychiatric request for help in a

somatic context. The consultation is aimed at offering help and knowledge to others who

have less expertise in the field of psychiatry. The consultation is offered in somatic

departments of general hospitals, nursing homes, rehabilitation centers, to general

practitioners, general practitioners’ practice support staff and primary care services.

Expertise in somatic comorbidity is essential.

Interference care Interference care is intended for people who have (an accumulation of) complex problems

and for whom the right care cannot be provided in time because they "cannot or do not

want to ask for help themselves; cannot make or maintain poor contact with regular care

providers or actively avoid help because they believe they do not have a problem; so fall

between the cracks in the existing support offer". (GGZ GHOR Nederland, GGZ Nederland,

KNMG, 2014). Interference care is imposed if no initiative can be expected from the person

concerned. Interference care aims to actively, outreach-wise and unsolicited help these

people to acknowledge and express their care needs, and then to guide them to regular care.

‘Setting up quarters’ is an important instrument in this. Increasing the quality of life and

reducing nuisance are the main priorities. Characteristic is the infringement of the right to

self-determination and self-determination in relation to the care recipient’s privacy and

autonomy. Integrity in the handling of information and confidentiality is part of interference

care, as is careful interaction with chain partners and a binding, seductive attitude towards

the care recipient.

46

4.5 The NP mental health care as coordinating practitioner

In the mental health care sector, the term 'coordinating practitioner' has been adopted on

the basis of the report of the Meurs Committee "Hoofdbehandelaarschap GGZ als

Noodgreep" (2015).

In the Dutch model quality charter for mental health care (Model Kwaliteitsstatuut GGZ,

2016), adopted by the professional organizations and sector parties in the mental health

care sector, the coordinating practitioner is further specified as the care provider who

coordinates the care process and is the first point of contact for the care recipient and his or

her relatives and/or legal representative. If care is provided by a single care provider, this is

by definition also the coordinating practitioner. In the case of multidisciplinary treatment,

the coordinating practitioner has a substantial share in the treatment as such. Furthermore,

the charter states that the coordinating practitioner must be appropriate to the type of

treatment and the target group. The NP mental health care functions best as a coordinating

practitioner when the consequences of the condition or disease are central.

The NP mental health care is logically the coordinating practitioner when it comes to the

care for or the supervision of (part of) a patient journey she carries out. She shall consult

another health professional, for example a medical specialist, in the event of requests for

help that lie outside her expertise.

4.6 The NP mental health care as co-care provider

The NP mental health care may be asked to take on a specific part of the treatment within

the framework of a larger treatment. This specific part may consist of more limited, complex,

routine medical treatments, or complex nursing treatments that are carried out within a

care process. She is then a co-care provider.

4.7 Specific competences of the NP mental health care

In addition to the aforementioned shared competences of the NP, the NP mental health care

differs from the NP somatic health care in the nature of the specialty-related competences

in the clinical expertise competency area. This section describes the specific competences

of the NP somatic health care, first in relation to the focus area, the area of expertise and

the spectrum of treatment, and then in relation to the treatment process.

47

4.7.1 Competences regarding the focus area, area of expertise and spectrum of treatment

Knowledge The NP mental health care has knowledge of:

• the diagnostic, therapeutic and preventive arsenal for common conditions in mental

health care;


within one or more of the following focus areas:

o child and adolescent psychiatry;

o adult psychiatry;

o gerontopsychiatry;


within one or more areas of expertise, including possibly the following:

o mild intellectual disabilities with psychiatric comorbidity;

o transcultural psychiatry;

o forensic psychiatry;

o addiction care.

Skills The NP mental health care is able:

• to provide mental health care in an effective, efficient and ethically responsible

manner within the aforementioned focus areas and areas of expertise;

• to act within the various components of the spectrum of treatment:

o clinical treatment;

o outpatient treatment;

o emergency treatment;

o consultative psychiatry;

o interference care;

• building, maintaining and concluding an effective treatment relationship in which the

person of the NP mental health care can also be used as a therapeutic tool; the NP

mental health care can use aspects of transference and countertransference;

• applying the diagnostic, therapeutic and preventive arsenal - where possible

evidence-based - using a combination of nursing methods and methods from other

disciplines, such as medicine15 and psychotherapy16;

• independently select, carry out and delegate reserved procedures.

15 In particular medical-psychiatric forms of treatment such as prescribing prescription drugs. 16 In particular psychodynamic, behavioural-therapeutic, group-dynamic, environmental-therapeutic and systemic interventions.

48

Attitude The NP mental health care is characterized by:

• the linking of nursing and medical treatment for the benefit of experienced health,

physical and/or psychological functioning, quality and dignity of life of the care

recipient.

4.7.2 Competences regarding the treatment process

The clinical expertise competency area includes specific competences so that the NP mental

health care is able to act as an independent practitioner within the focus area, the expertise

area and the spectrum of treatment. The description follows the treatment process.

The NP mental health care is able:

• to purposefully collect information:

o knows the principles of taking a medical history, heteroanamnesis and

biography in mental health care;

o can apply this in the assessment of care recipients;

• to assess the need for and carry out diagnostic interventions:

o knows the principles of psychiatric research, including structured interview

techniques, psychotherapeutic interview techniques, assessment

instruments and questionnaires;

o can perform psychiatric tests;

o knows the principles of physical examination in mental health care and

specifically within her focus area and area of expertise;

o can carry out physical examination within mental health care and specifically

within her focus area and area of expertise;

o knows the common additional examination techniques (including imaging

techniques and laboratory tests) within mental health care and specifically


o can apply these examination techniques within mental health care and


• to make a differential diagnosis based on clinical reasoning and to make the right

decisions:

o is familiar with the principles of clinical reasoning and differential diagnosis

within mental health care and specifically within her focus area and area of

expertise;

o is able to make a differential diagnosis within mental health care and


• to assess the need for and carry out therapeutic interventions:

49

o knows the effects (pharmacodynamics and pharmacokinetics), side effects,

contraindications and interactions of commonly used drugs in mental health

care;

o has specialist knowledge of the effects (pharmacodynamics and

pharmacokinetics), side effects, contraindications and interactions of drugs

(including psychopharmaceuticals) within her focus area and area of

expertise;

o is competent to act in the prescription of medicines (including

psychopharmaceuticals) within the mental health sector, specifically within

her focus area and area of expertise;

o is familiar with the principles of medical-psychiatric forms of treatment in

mental health care and specifically within the focus area and the area of

expertise (including reserved procedures including the prescription of

prescription drugs, and psychodynamic, behavioral therapeutic, group

dynamic, environmental therapeutic and systemic interventions);

o can apply these forms of treatment in the right context and in the right way


• to evaluate whether the set objectives have been achieved:

o knows the principles of referral to other mental health specialists;

o has specialist knowledge of referral to other specialists within her focus area

and area of expertise, including referral to somatic health care;

o can refer care recipients adequately within mental and somatic health care,

specifically with regard to her own focus area and area of expertise;

o has knowledge of principles of transfer of care to other healthcare providers

within mental health care and follows the patient journey;

o can adequately transfer care to other healthcare providers and follows the

patient journey;

o has knowledge of principles of follow-up and discharge specifically with

regard to her focus area and area of expertise;

o can adequately follow up the request for help and/or terminate the

treatment;

o can determine a natural death and/or refer to the municipal coroner in case

of suspicion of a non-natural death;

• to coordinate the treatment and the care process:

o knows the principles of coordinating the treatment and the total care

process;

o can function as an independent practitioner and, if possible, if the patient

journey makes this desirable, as a coordinating practitioner.

50

Literature

Bruijn-Geraets, D.P. de, Bessem-Beks, M.C.M., Eijk-Hustings, Y.J.L. van, & Vrijhoef, H.J.M.

(2015). VoorBIGhouden, Eindrapportage Evaluatieonderzoek Art. 36a Wet BIG met

betrekking tot de inzet van de Verpleegkundig Specialist en de Physician Assistant.

Maastricht: Maastricht UMC+, Patiënt en Zorg, KEMTA.

Bruijn-Geraets, D.P. de, Eijk-Hustings, Y.J.L. van, Castro-Soerland, N. van, & Vrijhoef, H.J.M.

(2016). VoorBIGhouden 2, Eindrapportage Evaluatieonderzoek Art. 36a Wet BIG met

betrekking tot de inzet van de Verpleegkundig Specialist en de Physician Assistant:

Endoscopie, electieve cardioversie, defibrillatie. Maastricht: Maastricht UMC+, Patiënt en

Zorg, KEMTA.

Buijse, A.M., & Plas, G.M. (2007). Inventarisatie van competenties en voorwaarden voor het

indiceren van voorbehouden handelingen door Verpleegkundig Specialisten en Physician

Assistants. Utrecht: Landelijk Expertisecentrum Verpleging & Verzorging.

College Specialismen Verpleegkunde (CSV). (2008a). Besluit verpleegkundig specialisme

acute zorg bij somatische aandoeningen CSV van 16 december. Utrecht: V&VN.

College Specialismen Verpleegkunde (CSV). (2008b). Besluit verpleegkundig specialisme

intensieve zorg bij somatische aandoeningen CSV van 16 december 2008. Utrecht: V&VN.

College Specialismen Verpleegkunde (CSV). (2008c). Besluit verpleegkundig specialisme

chronische zorg bij somatische aandoeningen CSV van 16 december 2008. Utrecht: V&VN.

College Specialismen Verpleegkunde (CSV). (2008d). Besluit verpleegkundig specialisme

preventieve zorg bij somatische aandoeningen CSV van 16 december 2008. Utrecht: V&VN.

College Specialismen Verpleegkunde (CSV). (2009). Besluit verpleegkundig specialisme

geestelijke gezondheidszorg CSV van 9 maart 2009. Utrecht: V&VN.

College Specialismen Verpleegkunde (CSV). (2016). Algemeen besluit CSV van 30 mei 2016.

Utrecht: V&VN.

Commissie Hoofdbehandelaarschap GGZ. (2015). Hoofdbehandelaarschap

GGZ als Noodgreep.

Frank, J.R., Snell, L., & Sherbino, J. (2015). CanMEDS 2015 Competency Framework.

Ottawa: Royal College of Physicians and Surgeons of Canada.

51

GGZ GHOR Nederland, GGZ Nederland, & KNMG. (2014). Handreiking

Gegevensuitwisseling in de bemoeizorg.

Huber, M., Knottnerus, J.A., Green, L., Horst, H. van der, Jadad, A.R., Kromhout, D.,

Leonard, B., Lorig, K., Loureiro, M.I., Meer, J.W. van der, Schnabel, P., Smith R., Weel, C.

van, & Smid, H. (2011). How should we define health? BMJ, 343. doi: 10.1136/bmj.d4163

Kaljouw, M., & Van Vliet, K. (2015). Naar nieuwe zorg en zorgberoepen. De contouren. Den

Haag: Zorginstituut Nederland.

Lambregts, J., & Grotendorst, A. (2012). Beroepsprofiel verpleegkundig specialist. Utrecht:

V&V 2020.

Landelijk Platform GGZ, NVvP, GGZ Nederland, Landelijke Vereniging van Vrijgevestigde

Psychologen & Psychotherapeuten, NIP, Ineen, MeerGGZ, V&VN, P3NL, &

Zorgverzekeraars Nederland. (2016). Model Kwaliteitsstatuut GGZ.

Poortvliet, P., & Uitewaal, A. (2017). Toekomstgerichte indeling verpleegkundig

specialisten. Advies. Utrecht: College Specialismen Verpleegkunde (CSV).

Stuurgroep Toekomstbestendige Specialismen. (2017). Toekomstgerichte indeling

verpleegkundig specialisten. Advies. Utrecht: auteur.

Taskforce Zorg op de Juiste Plek. (2018). De juiste zorg op de juiste plek. Den Haag:

ministerie van Volksgezondheid, Welzijn & Sport.

Ter Maten-Speksnijder, A.J. (2016). Finding Florence: Shedding Light on Nurse Practitioners'

Professional Responsibility. Rotterdam: Erasmus University Rotterdam.

Tracy, M.F., & O’Grady, E.T. (2019). Hamric and Hanson's Advanced Practice Nursing. An

Integrative Approach. St. Louis: Elsevier.

University of Cambridge Institute for Manufacturing (IfM), & International Business

Machines Corporation (IBM). (2008). Succeeding through service innovation: A service

perspective for education, research, business and government. Cambridge: University of

Cambridge Institute for Manufacturing.

World Health Organization (WHO). (2001). Nederlandse vertaling van de ‘International

Classification of Functioning, Disability and Health’. Bilthoven: WHO FIC Collaborating

Centre in the Netherlands, RIVM.

53

Content

Annex 1 - Realization of the professional competency framework .............................. 54

Revision of the professional competency framework ................................................... 54

Consultation of a broad group ....................................................................................... 54

Names of people involved .............................................................................................. 56

Annex 2 - Developments in the demand for care, care provision and health ............... 57

Developments in demand for care ................................................................................. 57

Developments in healthcare provision........................................................................... 57

Changing views on health ............................................................................................... 58

What do these developments mean for the Nurse Practitioner? .................................. 59

Annex 3 - Development of the profession .................................................................. 60

Principles of Advanced Practice Nursing ........................................................................ 60

Development of the profession in the Netherlands ...................................................... 60

Advanced Nursing Practice in the Netherlands .............................................................. 62

Annex 4 - Collaboration with other healthcare professionals ...................................... 63

Annex 5 - Glossary ..................................................................................................... 65

Literature .................................................................................................................. 71

54

Annex 1 - Realization of the professional competency

framework

Revision of the professional competency framework

The section V&VN VS was in charge of the revision of the professional competency

framework. For this purpose, a working group was set up in January 2018 under the

leadership of Jaap Kappert17. Members of the working group were Irma de Hoop18, Arnout

Uitewaal19, Paul Poortvliet20, and Caroline van Mierlo21.

The competences of the NP as stated in the 2012 professional competency framework

(Lambregts & Grotendorst, 2012) formed the basis for the revision of the professional

competency framework. A broad group was also involved in the revision. First of all, the NPs

themselves; after all, the professional competency framework concerns this professional

group. In addition, the section V&VN VS attached great importance to reflection from the

sector organizations, the education sector and the professional organizations of related

professions. NPs work closely with other professionals and have a key position within

healthcare organizations. A clear and recognizable professional competency framework

contributes to a clear positioning and good mutual cooperation. The board of V&VN VS also

wished the professional competency framework to fit in well with the transitions in

healthcare and society.

Consultation of a broad group

The first version of the professional competency framework has been reviewed by the V&VN

VS board. In April 2018, the second version was submitted to networks of NPs in a written

round of comments. Nine networks responded. The reactions were incorporated in a third

version.

This third version was discussed with Nurse Practitioners at three meetings in Rotterdam

(Rotterdam University of Applied Sciences), Utrecht (V&VN) and Groningen (Hanze

University of Applied Sciences) in May 2018. In total, more than fifty NPs attended these

meetings.

The third version was also commented on by the project group and the sounding board

group of the 'Implementation of the Future-oriented Classification of Nursing Specialties'

program (Poortvliet & Uitewaal, 2017). This process has established links between the new

17 Nurse Practitioner, secretary of the section V&VN VS (until 1 August 2018) and advisor V&VN and policy

advisor V&VN VS (from 1 August 2018). 18 Nurse Practitioner and president of the section V&VN VS. 19 Secretary Council for Nurse Practitioners (CSV). 20 External project leader for the project ‘Implementation Nursing Specialisms’. 21 Advisor V&VN, coordinator for the professional competency frameworks for care assistant, nurse,

coordinating nurse and Nurse Practitioner.

55

classification of nursing specialties, the revision of the professional competency framework,

the educational framework and the regulations of the Council for Nurse Practitioners

(College Specialismen Verpleegkunde [CSV]) and the Registration Commission for Nurse

Practitioners (Registratiecommissie Specialismen Verpleegkunde [RSV]). The project group

and sounding board group then discussed the fourth version, which was edited into a fifth

version, which was discussed again. Again, networks of NPs were invited to comment. Ten

networks and a few individual NPs took advantage of this opportunity. Meanwhile it was

October 2018. An overview of the reactions can be requested from V&VN VS.

Sectoral organizations from elderly care, mental health care, general hospitals and university

hospitals (Actiz, GGZ NL, NVZ and NFU) were represented in the sounding board group

and/or the project group and discussed the professional competency framework with their

supporters. Proposals resulting from these consultations have been fed back.

The following professional organizations were invited to comment. The Federation of

Medical Specialists (FMS), the Elderly Care Physicians Association (Verenso), the General

Practitioner Association (LHV), the Physician Assistants Association (NAPA), the Netherlands

Psychologists Institute (NIP), the Federation of Healthcare Psychologists and

Psychotherapists (FGzPt), the Netherlands Association for Healthcare Psychology (NVGzP),

the Association for Hospital Medicine (VvZ) and the Medical Student Organization (De

Geneeskundestudent). All accepted the invitation, although instead of the FGzPT, the

Council for Healthcare Psychologists and Psychotherapists (CSGP) participated.

The educational sector was involved at an early stage to enable a smooth transition to a new

educational framework. The aforementioned project group included two representatives

from a university of applied sciences. They coordinated with colleagues in a consultative

body which includes a representation of the universities of applied sciences that offer a

MANP program (nine universities of applied sciences and the NP mental health care

educational institution). In addition, the secretary and president of V&VN VS received

suggestions from other senior trainers of MANP programs.

Finally, with the help of Ko Hagoort, an edited version was produced that was submitted to

the Sounding Board Group, the project group, the board of V&VN VS and the board of V&VN.

The board of V&VN VS adopted the professional competency framework on Wednesday 09

January 2019. Finally, the board of V&VN adopted the professional competency framework

on 25 January 2019. This competency framework was translated into English by Ko Hagoort

in the spring of 2019.

56

Names of people involved

Project group for the implementation of nursing specialties

Name Position Representing

Ada ter Maten-Speksnijder ‘Practor’, Apprenticeships Albeda College V&VN VS

Wim Breeman Acute somatic care Nurse Practitioner /

lecturer MANP program at Rotterdam

University of Applied Sciences

V&VN VS

Peter Goossens Nurse Practitioner mental health care /

visiting professor mental health nursing at

Ghent University, Belgium

V&VN VS

Irma de Hoop Nurse Practitioner mental health care /

president V&VN VS

V&VN VS

Marjolijn Broers Chronic somatic care Nurse Practitioner Actiz

Yvonne Haar Chronic somatic care Nurse Practitioner Actiz

Jolanda ter Sluysen Director of care professions educational

programs, Radboudumc Academic Hospital

NFU

Kees Spitters Growth and Strategy Manager GGzE GGZ NL

Riet Janssen Program manager MANP program Fontys

University of Applied Sciences

LOO

Rob Bakker Director GGZ Verpleegkundig Specialist LOO

Arnout Uitewaal Secretary CSV

Paul Poortvliet Project leader

The RSV (Bas Vogel) was optionally invited.

Sounding board group for the implementation of nursing specialties

Name Position Representing

Milena Babovic Director NAPA

Sophie Osseweijer-

Bronsgeest

Intensive somatic care Nurse Practitioner V&VN VS

Jeanet van Essen Nurse Practitioner mental health care V&VN VS

Liedy Vennegoor Chair, Executive Board Careaz wonen,

welzijn en zorg

Actiz

Petrie Roodbol Professor of Nursing Science NFU

Lucyl Verhoeven-de Laat Intensive somatic care Nurse Practitioner NVZ

Jettie Tolman Educational programs consultant Gelre

Ziekenhuizen

NVZ

Paul Poortvliet Project leader

57

Annex 2 - Developments in the demand for care, care

provision and health

Developments in demand for care

The demand for care is rising in the Netherlands. In addition, the demand for care is also

changing for various reasons. The number of elderly people is increasing. More people suffer

from one or more chronic conditions, live longer at home and more often visit an emergency

room. In addition, medical and technological developments offer more and more

possibilities. All this increases the scope, the care intensity, but also the costs for care

(Taskforce Zorg op de Juiste Plek, 2018).

The Netherlands National Institute for Public Health and the Environment (RIVM) describes

a number of trends in healthcare up to 2030 in its 2018 Public Health Future Exploration

(RIVM, 2018). One in three Dutch people will then have two or more chronic conditions. The

number of Dutch people with at least one chronic disease is expected to increase from 8.5

million in 2015 to 9.8 million in 2040. This concerns diseases such as osteoarthritis, visual

disorders, diabetes, coronary heart disease, hearing disorders, stroke, cancer, neck and back

problems, COPD, asthma, and heart failure. The number of people diagnosed with dementia

is expected to increase from 154,000 in 2015 to 330,000 in 2040. In 2040, cancer,

cardiovascular disease and mental disorders will be the diseases that cause the most disease

burden.

The life-time risk of developing a psychiatric disorder is 42.3% in women and 44.7% in men.

Approximately 43.5% of all Dutch people aged 18-64 suffer from a mental disorder at some

point (Trimbosinstituut, 2010). Cross-sectionally, approximately 18% of the Dutch

population suffers from a psychiatric disorder (Trimbosinstituut, 2010). The number of

people with two or more mental disorders will increase. In 2013, 280,000 people had a

serious psychiatric disorder as defined by DSM-V (Delespaul et al., 2013, in Trimbosinstituut,

2014). In addition, care recipients in mental health care often have recurrent problems.

Developments in healthcare provision

The RIVM expects that, partly due to the provision of health care, chronically ill people will

continue to participate in society. Health care is increasingly provided in or close to home

and aims to allow the care recipient to autonomously take control. This is achieved by

supporting self-management and promoting empowerment, aimed at increasing or

maintaining the quality of life. However, not everyone is able to do this, for example because

of a low level of education, vulnerable health or less sound judgement.

58

The trend towards increasing multimorbidity and deinstitutionalization of health care

requires integrated, multidisciplinary care (LOOV, 2015; FMS, 2012). Multidisciplinary teams

of healthcare professionals have all the competences in this area (Kaljouw & Van Vliet,

2015). People with complex and multiple requests for help benefit greatly from chain care,

network care and/or care arrangements from multidisciplinary teams. In the future, curative

care and non-curative chronic care will be less demarcated from each other, so that

cooperation in the care sector will be increasingly of a supra-sectoral nature (Invoorzorg,

2015).

Technological developments also have consequences for the provision of health care – and

therefore also for the shaping of professions in the healthcare sector (Kaljouw & Van Vliet,

2015). These technological developments may provide new opportunities for someone to

function independently and to carry out self-management (RIVM, 2018).

In addition to the emphasis on the importance of generalist and agile care professionals,

there is also a trend towards specialization. After all, serious and complex disorders will

continue to require specialist knowledge and skills in the future (Kaljouw & Van Vliet, 2015).

Changing views on health

NPs function within the views on health and disease that have become established in society

and in health care. These views on health and disease have changed in recent years.

In 1948, the World Health Organization (WHO) described health as "a state of complete

physical, mental and social wellbeing and not merely the absence of disease or infirmity.” In

the Netherlands’ nurses professional competency framework from 1999, this description is

another focal point for nursing care. It is now clear that such a situation is not feasible for

most people. From this perspective, almost the entire world population would be unhealthy.

In addition, this description does not do justice to one's ability to cope with physical,

emotional and social challenges on one's own. Even with a disorder, illness or disability, a

meaningful life with well-being is possible.

Meanwhile, various groups within the population – including policy makers – are advocating

a different approach to the concept of health. This is a paradigm shift from the medical

model to a biopsychosocial model. The approach proposed by physician-researcher

Machteld Huber is illustrative. She describes health as: "The ability to adapt and self-manage

in the face of social, physical, and emotional challenges" (Huber et al., 2011). The focus is

not on the condition (or its absence), but on adaptability and self-management.

59

NPs use various approaches to health in their daily practice. Machteld Huber's approach

helps to see health more broadly than just the absence of disease. This approach is

mentioned, in the knowledge that other approaches to health also exist and that this

particular approach has also been criticized.

Jaap van der Stel (2016), for example, believes that the biopsychosocial aspect is missing

from the description of Machteld Huber. He understands health to mean: "being able to

maintain and develop the physical, psychological and social functions necessary in view of

the phase of life and living conditions, partly through one's own efforts and according to

one's well-being".

What do these developments mean for the Nurse Practitioner?

The developments outlined above have consequences for the working method of the NP.

She will not only provide patient care within her own organization, but will increasingly

follow the care recipient, for example by providing (part of) the treatment at the care

recipient's home. This can also be done by using eHealth. The NP’s collaboration partners

will also function just as much within and outside the own organization.

In addition, the NP will increasingly act as a coordinating practitioner. This means that she is

the practitioner who directs the care process of an individual care recipient. An important

part of this role is supporting the self-management of care recipients, so that they can

(re)direct their own lives.

The NP will also need both generalist and specialist competences to be prepared for the care

demand of the future.

60

Annex 3 - Development of the profession

Principles of Advanced Practice Nursing

The principles of the profession are derived from the concept of Advanced Practice Nursing

(APN), developed in the United States as: "the patient-focused application of an expanded

range of competencies to improve health outcomes for patients and populations in a

specialized clinical area of the larger discipline of nursing" (Tracy & O'Grady, 2019). In the

Netherlands, the term 'Advanced Nursing Practice' is used for this purpose.

The American Association of Colleges of Nursing (2004) defines Advanced Nursing Practice

as: "any form of nursing intervention that affects health outcomes for individuals or groups,

including direct care for individual patients, care management for individuals or groups, the

management of nursing and healthcare organizations, and the development and

implementation of healthcare policies" (Tracy & O'Grady, 2019).

The International Council of Nurses (ICN) defines the APN professional as follows: "A Nurse

Practitioner/Advanced Practice Nurse is a registered nurse who has acquired the expert

knowledge base, complex decision-making skills and clinical competencies for expanded

practice, the characteristics of which are shaped by the context and/or country in which s/he

is credentialed to practice. A master's degree is recommended for entry level" (ICN, 2001-

2018).

Seven core competencies are distinguished: direct clinical practice, advice and coaching,

consultation, evidence-based practice, leadership, collaboration and ethical decision-

making. The first – direct clinical practice – is also figuratively paramount (Tracy & O'Grady,

2019). According to the ICN, possession of these competencies leads to, among other things,

the right to diagnose, prescribe drugs, recommend treatments, refer care recipients to other

healthcare professionals and the right to admit care recipients to hospital (ICN, 2001-2018).

Various differentiations can be distinguished within Advanced Practice Nursing (professional

name 'advanced practice nurse'), including those of the Advanced Nurse Practitioner (ANP)

and Clinical Nurse Specialist (CNS).

Development of the profession in the Netherlands

The NP profession in the Netherlands is still young. In 2009, it was acknowledged as a

specialty in accordance with Article 14 of the BIG Act and registered under this protected

professional title. However, the development of the profession has a longer history.

61

The NP mental health care profession already existed before the recognition of the specialty

in the BIG Act. Since 1998, these NPs have been trained via a three-year higher professional

education course. In 2009, this course was awarded the MANP degree in education (NVAO,

2009).

The VO-SPV course (advanced training of social psychiatric nurses) at Utrecht University of

Applied Sciences also formed a run-up to the NP profession. Social psychiatric nurses had

already been trained as practitioners before the BIG Act (1997) came into force. Until the

bachelor-master structure was introduced, the advanced course was the 'highest' clinical

course. At that time, social psychiatric nurses had followed the Bachelor of Nursing (or an

old in-service psychiatric nursing training), supplemented by the MGZ-GGZ (abbreviated

HBO) and the VO-SPV. In 2006, the VO-SPV was completely absorbed by the two-year mental

health care MANP.

The Nurse Practitioner entered the somatic health care system in the Netherlands around

2000. These nursing care professionals were deployed to promote, among other things,

continuity and quality of care, initially only in hospitals. For example, they provided care in

neonatal intensive care departments in the context of task substitution according to the

NANNP model (NANNP Council, 2013); care that traditionally belonged in the medical

domain. Gradually, more and more Nurse Practitioners came into being, also in primary care

and care for the elderly.

More and more official authority was added. As of 2012, the NP has an independent practice

authority for a number of reserved procedures on an experimental basis. On 1 September

2018, this was converted into a definitive independent practice authority. The NP also

became authorized to invoice fees. NPs can authorize Diagnosis-Treatment Combination

healthcare products22 since 2015, and from 1 January 2019 they can also independently

invoice peer consultation and co-treatment fees. The NP will also be given the opportunity

to invoice activities under the Chronic Care Act. Since 2017, the NP has been a coordinating

practitioner in mental health care. Evaluations about patient safety, efficiency and

effectiveness in the context of the profession are positive (De Bruijn-Geraets et al., 2015; De

Bruijn-Geraets et al., 2016).

The growing professional group is increasingly organizing itself, both in a strong professional

association and in networks. In recent years, networks of NPs with a specific area of

expertise have emerged. Some networks have grown to several hundred members. These

networks focus on training, on the positioning of the NP, and on the development of the

area of expertise in a specific field of work.

22 The cost of hospital treatment in the Netherlands is determined by what is known as a Diagnosis-Treatment Combination (DBC in Dutch). This diagnosis treatment combination is also called a DBC healthcare product.

62

The number of NPs is expected to increase further in the coming years. For a further

overview of the history of the NP in the Netherlands, please refer to the professional

competency framework of NP 2012 (Lambregts & Grotendorst, 2012; Appendix 1) (in Dutch).

The Bachelor of Nursing program is the basic program required for entry in the Master of

Advanced Nursing Practice program. This means that the (future) profession of ‘coordinating

nurse’ forms the basis for the NP profession.

Advanced Nursing Practice in the Netherlands

The concept of Advanced Nursing Practice in the Netherlands contains characteristics of the

competencies of both the ANP and the CNS. However, the ANP focuses more on direct

patient care while the CNS focuses more on quality care, care management and policy

(Bryant-Lukosius & Kam Yuet Wong, in Tracy & O'Grady, 2019).

Advanced Nursing Practice goes further than specialization in an area within nursing alone,

as evidenced by the broad independent practice authority and the master's program at NLQF

level 7. The NP therefore distinguishes herself from nurses with an advanced specialist

training.

Hamric and Tracy (in Tracy & O'Grady, 2019) describe the differences between nurses with

an advanced specialized training and advanced practice nurses as follows. Advanced practice

nurses have:

• new knowledge and skills, particularly evidence-based knowledge and knowledge of

a theoretical nature, which sometimes transcend the traditional boundaries of

medicine;

• a significant or more significant role autonomy;

• responsibility for health promotion, diagnosis and treatment of patient problems,

including pharmacological and non-pharmacological interventions;

• greater complexity of clinical reasoning and decision-making, as well as the greater

degree of leadership in organizations and the care environment;

• specialization in a particular sub-area and/or for a particular patient group.

In addition, in the Netherlands, task substitution has continued to take shape in recent years.

The Council for Public Health and Healthcare (2002) has defined task substitution as follows:

"the structural reallocation of tasks between different professions". This reallocation of tasks

ultimately led to the independent practice authority of the NP for the needs assessment,

execution and delegation of reserved procedures, which she uses to function as an

independent practitioner.

63

Annex 4 - Collaboration with other healthcare professionals

Healthcare is increasingly becoming a matter for multidisciplinary teams of healthcare

professionals. These should be composed in such a way that adequate, tailor-made care can

be provided to people with, for example, chronic disorders, multimorbidity, functional

problems and psychological disorders. The most important professional groups with which

the NP collaborates are listed below. The list is not exhaustive. Cooperation always takes

place on the basis of recognition of mutual competences and skills.

Care assistants, nurses and coordinating nurses

The NP often works together with care assistants, nurses and coordinating nurses. As the

level of education and/or in-depth professional knowledge increases, so does the complexity

and autonomy of their practice. These care professionals all function as holistic professionals

with the central aim of promoting a care recipient’s ability to function independently and to

retain control of his or her own life through self-management and empowerment and to

keep the perceived quality of life as high as possible.

The NP has an important role in the coaching, supervision and education of care assistants,

nurses and coordinating nurses. In this way, the NP, in cooperation with the team, can

improve the quality of a care team.

In addition, the NP, as an independent qualified professional, may delegate the execution of

reserved procedures to care assistants, nurses and coordinating nurses pursuant to Article

36 of the BIG Act, with due observance of Articles 35 and 38 of the BIG Act (careful

assignment/giving orders, giving functional instructions and ensuring supervision and

intervention).

The areas of expertise of the care assistants, nurses and coordinating nurses are described

in the respective professional competency frameworks of these professionals.

Nurse scientists

Nurse scientists initiate, set up and conduct scientific research. The NP is also active in this

field, but has a different focus. After all, the research component in the NP field is always in

the light of patient treatment. A NP can carry out scientific research, but is first and foremost

a practitioner. In practice, NPs and nurse scientists, clinical epidemiologists and others work

together to carry out (clinical) scientific research.

64

Physicians and medical specialists

The NP has taken over tasks previously reserved for physicians. The NP is integrating medical

diagnostics and medical treatment into her treatment.

The NP also has an important role in coaching, supervising and teaching physicians (in

training) and physicians in training as specialists. In this way, the NP can promote the quality

of a care team and inter-professional cooperation.

Healthcare psychologists and psychotherapists

NPs work together with healthcare psychologists, clinical psychologists, clinical

neuropsychologists and psychotherapists. Here, too, there is a reallocation of tasks.

Treatments that used to be performed only by these professions have now also become part

of the NP field of work.

Physician assistants

The NP works with physician assistants. The physician assistant works as a professional in

the medical domain, where the NP offers integrated medical and nursing treatment. The

content of the two master's programs is different, although the preparatory program may

be the same and the fields of work may overlap considerably.

65

Annex 5 - Glossary

Area of expertise

A description of the specific knowledge, skills and attitude that the NP must have at her

disposal, complementary to the expertise as described in the shared competency area and

the focus areas within the somatic and mental healthcare specialties (College Specialismen

Verpleegkunde, 2016). The word 'specific' can refer to a health problem, a cluster of medical

conditions, a life phase, a setting or a vision on care.

Clinical reasoning

The continuous, cyclical process of data collection and analysis aimed at the questions and

problems of an individual care recipient and his or her relatives, in relation to health and

disease. This includes risk assessment, early detection, problem recognition, intervention

and monitoring, in order to arrive at an integrated treatment plan (Lambregts &

Grotendorst, 2012). Risk assessment is understood to mean the determination of the nature

of the disease/disorder, the resulting health risks, the risks and possible side-effects of

therapeutic options, the risks of the applied reserved procedures and the expected effects

thereof, based on the findings of the anamnesis, physical and/or psychiatric examination

and additional examination, within the relevant area of expertise. Early detection implies

the observation, examination and diagnosis of the care recipient with the aim of being able

to detect changes in the care recipient’ health status in a timely manner.

Competence

A competence is a combination of knowledge, skills and attitude (Lambregts & Grotendorst,

2012).

Competency area

The competency area is the field in which the NP somatic health care and the NP mental

health care are professionally autonomous (Terpstra et al., 2015). This means that NPs in

this field can independently give substance to the profession. In these situations, they

independently make effective choices in the care process. They are responsible for this and

can be held responsible for it.

Complexity of the care situation

The characteristics below may influence the complexity of the care situation according to a

literature study by Guarinoni et al. (2014), copied from Van Straalen and Schuurmans (2017):

• the personal characteristics of the patient: personal demographic data, lifestyle,

personal ability and available knowledge to make health decisions;

66

• clinical characteristics: medical diagnosis, the degree of (in)certainty of the diagnosis,

therapy and care, chronicity, physical function and disability, cognitive functioning,

nutritional status, severity of the condition and severity of the symptoms,

complications, multipathology, geriatric disorders, urgency of the situation, critical

or less critical status;

• care characteristics: nurse diagnoses, interventions and outcomes, intensity of single

nurse care activities, extent to which allied healthcare professionals are involved, for

example physiotherapists and GPs;

• social characteristics: social functioning, stability in the living situation, extent to

which the patient has a support system, socio-economic situation, cultural

circumstances, availability of technology;

• characteristics of the care system: characteristics of the care organization, degree to

which expert personnel is available, degree to which there is a need for coordination

of the care, availability of technology, quality of the services of an organization, way

in which patients are allocated to individual care providers and the resulting

caseload.

It depends on the clinical reasoning ability of the NP whether all relevant data are correctly

included in a decision. In this way, personal clinical reasoning is linked to the complexity of

care situations and vice versa.

Coordinating practitioner

A coordinating practitioner is defined as being responsible for the integrality and

coordination of the treatment process. The NP will then be the first point of contact for all

parties involved, including the care recipient and his relatives and/or legal representative.

The report of the Meurs Committee (2015) defines the coordinating practitioner as: "the

professional who is responsible for directing the care process of an individual patient.”

eHealth

The application of modern information and communication technology for the benefit of

healthcare (Pagliari, 2005, in Krijgsman & Klein Wolterink, 2012).

Empowerment

Empowerment is to empower others by encouraging and authorizing them. Empowerment

is about sharing power with others, including patients, and enabling them to seize or assert

it. Empowerment is more than encouraging others to act independently. It is a development

process that grows over time and contributes to a sense of competency, responsibility,

independence and capacity to act (Carter & Reed, in Tracy & O'Grady, 2019).

67

Evidence-based practice

Evidence-based practice concerns the explicit, judicious and conscientious use of the best

available (scientific) evidence, including experiential knowledge and best practices, and

considering the preference (possibly based on previous experience) of the care recipient

when making choices and performing procedures (Terpstra et al., 2015).

Focus area

Area within the nursing specialty to which the NP pays most attention in her professional

practice. The focus areas are in line with the currently usual sectors in somatic health care.

In the mental health care sector, the focus areas are oriented on developmental psychology.

Van Dale Groot dictionary of the Dutch language defines the focus area as "the area on which

one concentrates one's attention, to which one pays the most attention" (Den Boon &

Hendrickx, 2015, p. 9).

Independent practice authority

Independent practice authority refers to the possibility for certain professionals defined in

the BIG Act to select (needs assessment), carry out and delegate reserved procedures as

referred to in Article 36 of the BIG Act without the intervention of other professionals.

Leadership

In the book "Verpleegkundig Leiderschap" (Nursing Leadership; Vermeulen et al., 2017),

leadership is defined as: "working together with colleagues from our own and other

disciplines as well as with patients and family to achieve value-driven care, appropriate to

the situation".

Carter and Reed (in Tracy & O'Grady, 2019) distinguish four forms of leadership: clinical

leadership, professional leadership, system leadership and policy leadership. Clinical

leadership is about representing the care recipient and optimizing the quality of care.

Professional leadership is about developing and supporting other NPs and other healthcare

professionals. System leadership is taking up a position in the organization or fulfilling an

(advisory) administrative role. Policy leadership relates to influencing healthcare policy.

Medical diagnosis

The systematic and analytical process of finding a solution to a medical problem by using a

variety of methods, including biomedical knowledge and knowledge of epidemiological data

such as incidence, gender and age, as well as prior knowledge and contextual factors

(Grundmeijer, Reenders & Rutten, 2009).

68

Medical treatment

Medical treatment means the treatment in the field of medicine as described in Book 7, Title

7, Section 5, Section 446, first paragraph, of the Dutch Civil Code with respect to the

agreement on medical treatment.

Procedures in the field of medicine are understood to mean:

a. all procedures - including examining and giving advice - directly related to a person

and aimed at curing the person of a disease, preventing the person from developing

a disease or assessing the person’s state of health, or providing obstetric assistance;

b. activities other than those referred to under a., directly related to a person, which

are performed by a physician or dentist in that capacity.

Mentalizing ability

The mentalizing ability is understood to mean understanding one's own feelings, thoughts,

intentions and desires as well as those of others (Dimence, 2018).

Needs assessment

In line with a nursing or medical diagnosis, making the choice of (selecting) the appropriate

treatment and/or support that the care recipient must receive in order to maintain or

improve (experienced) health, physical and/or psychological functioning, quality of life and

dignity of life (Terpstra et al., 2015).

Nursing diagnosis

A nursing diagnosis is a clinical assessment of the experiences and/or reactions of an

individual, family or community regarding actual or potential health problems and/or life

processes, which provides the basis for the selection of nursing interventions to achieve

results, and for which selection, interventions and results the nurse is responsible (De Graaf-

Waar, 2014).

Nursing treatment

Nursing treatment forms the whole of nursing interventions for different nurse diagnoses.

Nursing interventions are one or more procedures, whether or not in connection with one

or more other patient/client related operations, all of which have a common goal and have

been chosen on the basis of nursing decision-making (McCloskey & Bulechek, 2002). This

concerns nursing procedures carried out on the basis of standards, guidelines, protocols, the

patient's own expertise and preferences, including examining and giving advice, as

stipulated in the Dutch Medical Treatment Contracts Act. Nursing treatment and nursing

care are synonyms. Nursing procedures and nursing interventions are also synonyms

69

Palliative care

Palliative care is care that improves the quality of life of patients and their loved ones

affected by life-threatening conditions or vulnerability, by preventing and alleviating

suffering, through the early detection and careful assessment and treatment of physical,

psychological, social and spiritual problems. During the course of the disease or

vulnerability, palliative care has an eye for maintaining autonomy, access to information and

choice (IKNL & Palliactief, 2017).

Patient journey

A patient journey is a concise representation of the different phases and events that a

fictitious patient/client experiences in the current reality or in the future when dealing with

his illness or physical complaint ("Patiëntenreis", z.d.).

Practitioner

The professional who carries out (part of) the treatment, who acts in accordance with the

professional (scientific) standard applicable to him. The practitioner carries out his share of

the treatment as laid down in advance in the individual treatment plan (Model

Kwaliteitsstatuut GGZ, 2016).

Prevention

Prevention focuses on increasing or maintaining the health, vitality and self-management of

people. A distinction is made between collective prevention (aimed at the entire population

and intended to actively identify persons with an increased risk and guide them to care in

good time), fit-for-purpose prevention (aimed at preventing the onset of illness or disability

in a person with an increased risk) and care-related prevention (aimed at preventing

aggravation of illness, the occurrence of complications and the onset of disabilities)

(Terpstra et al., 2015).

Professional standard

The professional standard contains standards that give substance to the practice of the

nursing care provider. Apart from professional rules, this also includes protocols and

guidelines, rules of conduct, general due diligence requirements and the standards from

legislation and regulations and case law. This concerns the generally accepted principles of

care provision (V&VN, 2015).

Quality of care

The quality of care is the extent to which healthcare in individuals and patient populations

improves the desired health outcomes. To this end, care must be safe, effective, timely,

efficient, equitable and people-oriented:

70

• safe means providing care that minimizes the risks and damage to care recipients,

including preventing avoidable injuries and medical errors;

• effective means providing care based on scientific knowledge and evidence-based

guidelines;

• timely means as little delay as possible in the provision of care;

• efficient means providing care in a way that uses a minimum of resources,

maximizing resource use and avoiding waste;

• equitable means providing care without distinguishing between personal

characteristics such as gender, race, ethnicity, geographical position or socio-

economic status;

• people-oriented means providing care taking into account the preferences and

wishes of individual care recipients, and the culture of their community (WHO, 2006).

Self-management

The individual ability of individuals to prevent health problems where possible and, when

they do occur, to cope with the symptoms, treatment, physical, psychological and social

consequences of health problems and lifestyle adjustments. This enables people to monitor

their own state of health and to react in a way that contributes to a satisfactory quality of

life (Terpstra et al., 2015).

Specialty

Article 14 of the BIG Act defines specialty as follows: "professionals who have acquired

particular expertise in the exercise of a particular sub-area of their profession". Specialty and

sub-area are synonyms.

Sub-area

Synonymous with specialty. See: specialty.

71

Literature

Boon, T. den, & Hendrickx, R. (met Sijs, N. van der, Etymologie). (2015). Groot

woordenboek van de Nederlandse taal (15de herziene editie). Utrecht: Van Dale.

Bruijn, de-Geraets, D.P., Bessem-Beks, M.C.M., Eijk-Hustings, Y.J.L. van, & Vrijhoef, H.J.M.

(2015). VoorBIGhouden, Eindrapportage Evaluatieonderzoek Art. 36a Wet BIG met

betrekking tot de inzet van de Verpleegkundig Specialist en de Physician Assistant.

Maastricht: Maastricht UMC+, Patiënt en Zorg, KEMTA.

Bruijn, de-Geraets, D.P., Eijk-Hustings, Y.J.L. van, Castro-Soerland, N. van, & Vrijhoef, H.J.M.

(2016). VoorBIGhouden 2, Eindrapportage Evaluatieonderzoek Art. 36a Wet BIG met

betrekking tot de inzet van de Verpleegkundig Specialist en de Physician Assistant:

Endoscopie, electieve cardioversie, defibrillatie. Maastricht: Maastricht UMC+, Patiënt en

Zorg, KEMTA.

Dimence. (2018). Mentaliseren bevorderende therapie. Op 5 november 2018 ontleend aan

https://www.dimence.nl/behandelingen/mentaliseren-bevorderende-therapie

Federatie Medisch Specialisten (FMS). (2012). Visiedocument De Medisch Specialist 2015.

Op 5 november 2018 ontleend aan

http://www.demedischspecialist.nl/sites/default/files/Visiedocument-De-Medisch-

Specialist0-2015.pdf

Graaf-Waar, H.I. de (Vert.). (2014). Nanda-International. Verpleegkundige diagnoses en

classificaties 2012-2014. Utrecht: Bohn Stafleu van Loghum.

Grundmeijer, H.G.L.M., Reenders, K., & Rutten, G.E.H.M. (2012). Het geneeskundig proces.

Klinisch redeneren van klacht naar therapie. Amsterdam: Reed Business.

Huber, M., Knottnerus, J.A., Green L., Horst, H. van der, Jadad, A.R., Kromhout, D., Leonard,

B., Lorig, K., Loureiro, M.I., Meer, J.W. van der, Schnabel, P., Smith, R., Weel, C. van, & Smid

H. (2011). How should we define health? BMJ, 343. doi: 10.1136/bmj.d4163

Integrale Kankercentra Nederland (IKNL), & Palliactief. (2017). Kwaliteitskader palliatieve zorg Nederland. Utrecht: IKNL.

International Council of Nurses (ICN). (2001-2018). Definition and Characteristics of the

Role. Op 5 november 2018 ontleend aan https://international.aanp.org/Practice/APNRoles

https://www.dimence.nl/behandelingen/mentaliseren-bevorderende-therapie

http://www.demedischspecialist.nl/sites/default/files/Visiedocument-De-Medisch-Specialist0-2015.pdf

http://www.demedischspecialist.nl/sites/default/files/Visiedocument-De-Medisch-Specialist0-2015.pdf

https://international.aanp.org/Practice/APNRoles

72

Invoorzorg. (2015). De langdurige zorg in 2020: trends organisatie. Op 5 november 2018

ontleend aan http://www.invoorzorg.nl/ivz/informatie-de-langdurende-zorg-in-2020-

trends-organisatie.html

Kaljouw, M., & Van Vliet, K.. (2015). Naar nieuwe zorg en zorgberoepen. De contouren.

Zorginstituut Nederland.

Krijgsman, J., & Klein Wolterink, G. (2012). Ordening in de wereld van eHealth. Den Haag:

Nictiz.

Lambregts, J., & Grotendorst, A. (2012). Beroepsprofiel verpleegkundig specialist. Utrecht:

V&V 2020.

Landelijk Overleg Opleidingen Verpleegkunde (LOOV). (2015). Bachelor Nursing 2020. Een

toekomstbestendig opleidingsprofiel 4.0. Landelijk Overleg Opleidingen Verpleegkunde.

Landelijk Platform GGZ, NVvP, GGZ Nederland, Landelijke Vereniging van Vrijgevestigde

Psychologen & Psychotherapeuten, NIP, Ineen, MeerGGZ, V&VN, P3NL, &

Zorgverzekeraars Nederland. (2016). Model Kwaliteitsstatuut GGZ.

McCloskey, J.C., & Bulechek, G.M. (2002). Verpleegkundige interventies [W. Seunke, I. van

Pinxteren, M. Merkus-Römgens, & H. Merkus, Vert.]. Maarssen: Elsevier gezondheidszorg.

National Association of Neonatal Nurse Practitioners (NANNP) Council (2013). Advanced

Practice Registered Nurse: Role, Preparation, and Scope of Practice. Position Statement

#3059. Op 19 november 2018 ontleend aan

http://nann.org/uploads/Membership/NANNP_Pubs/APRN_Role_Preparation_position_st

atement_FINAL.pdf

Nederlands-Vlaamse Accreditatie Organisatie (NVAO). (2009). Hbo-master verpleegkundig

specialist / ANP ggz.

Patiëntenreis. (z.d.). Geraadpleegd op 13 december 2018, van

https://www.participatiekompas.nl/methoden-en-tools/patiëntenreis

Poortvliet, P., & Uitewaal, A. (2017). Toekomstgerichte indeling verpleegkundig

specialisten. Advies. Utrecht: College Specialismen Verpleegkunde (CSV).

Raad voor de Volksgezondheid en Zorg (RVZ). (2002). Taakherschikking in de

gezondheidszorg. Zoetermeer: auteur.

http://www.invoorzorg.nl/ivz/informatie-de-langdurende-zorg-in-2020-trends-organisatie.html

http://www.invoorzorg.nl/ivz/informatie-de-langdurende-zorg-in-2020-trends-organisatie.html

http://nann.org/uploads/Membership/NANNP_Pubs/APRN_Role_Preparation_position_statement_FINAL.pdf

http://nann.org/uploads/Membership/NANNP_Pubs/APRN_Role_Preparation_position_statement_FINAL.pdf

https://www.participatiekompas.nl/methoden-en-tools/patiëntenreis

73

Rijksinstituut voor Volksgezondheid en Milieu (RIVM). (2018). Volksgezondheid

Toekomstverkenning 2018: Een gezond vooruitzicht. Synthese.

Stel, J. van der. (2016). Biopsychosociaal aspect ontbreekt in omschrijving van Machteld

Huber. Medisch Contact.

Straalen, L. van, & Schuurmans, M. (2017). Klinisch redeneren voor verpleegkundigen.

Houten: Bohn Stafleu van Loghum.

Taskforce Zorg op de Juiste Plek. (2018). De juiste zorg op de juiste plek. Den Haag:

ministerie van Volksgezondheid, Welzijn & Sport.

Terpstra, D., Berg, A. van den, Mierlo, C. van, Zijlstra, H., Landman, J., Schuurmans, M., &

Kempff, M. (2015). Toekomstbestendige beroepen in verpleging en verzorging. Rapport

stuurgroep over de beroepsprofielen en de overgangsregeling. Utrecht: BOZ, NU’91, LOOV,

MBO-raad & V&VN.

Tracy, M.F., & O’Grady, E.T. (2019). Advanced Practice Nursing. An Integrative Approach.

St. Louis: Elsevier.

Trimbosinstituut. (2010). De psychische gezondheid van de Nederlandse bevolking.

NEMESIS-2: Opzet en eerste resultaten. Utrecht: auteur.

Trimbosinstituut. (2014). Trendrapportage GGZ. Themarapport Persoonlijk en

maatschappelijk herstel van mensen met ernstige psychische aandoeningen.

Ontwikkelingen in praktijk en beleid. Utrecht: auteur.

Vermeulen, H., Holleman, G., Huis, A., Ista, E., & Lalleman, P. (2017). Verpleegkundig

leiderschap. Houten: Bohn Stafleu van Loghum.

Verpleegkundigen & Verzorgenden Nederland (V&VN). (2015). De professionele standaard,

een uitwerking. Visie van de beroepsvereniging Verpleegkundigen & Verzorgenden

Nederland. Utrecht: auteur.

World Health Organization (WHO). (2006). Quality of care. A process for making strategic

choices in health systems. Genève: auteur.

nurse practitioner professional competency framework

Documents